THE HUMAN EXTREMITIES MECHANICAl DIAGNOSIS AND THERAPY BY ROBIN MCKENZIE AND STEPHEN MAY The ab ility to treat musculoskeletal d isorde rs affecting the soft tissues and joints of the body is a relatively modem concept. In the past, pain, stiffness and injury were sim ply tolerated until the body adapted or broke down completely. Rep e titive Strain
Injury, 'housemaid's knee', tennis elbow and general physical dysfunction were accept of life's ageing process. However, improved social structure and treatment
ed as part
for these conditions mean that people expect to be able to regain good health, and want instant remedies for their pain. Numerous health care providers
-
family physicians, phYSiotherapists, chiropractors,
acupuncturists, naturopaths and osteopaths, among others - treat the painful symp toms of musculoskeletal conditions. These practitioners are so m etime s loath to admit defeat when the patient does not
respond
to traditional treatment. Patients put their
clinician in c harge of curing their condition and expect them to "do something". Often the patient is the first to give up, resigned to the belief that they cannot regain their physical health. The authors draw u p on current published scientific evidence which overwhelmingly identifies controlled movement and exercise as the most effective means of alleviating
pain and restoring function in patients with common musculoskeletal disorders. This latest text by Robin McKenzie and co-author Stephen May, allows the clinician
to provi d e the same self-treatment philosophy and management strategies first
described in McKenzie's text The Lumbar Spine, Mechanical Diagnosis and Therapy. These rarely discussed concepts are presented in straightforward language and are supported with over 100 photographs and illustrations. Other books by Robin McKenzie include Treat Your Own Back, Treat Your Own Neck,
The Lumbar Spine: Mechanical Diagnosis and Therapy, and The Cervical and Thoracic Spine: Mechanical DiagnOSiS and Therapy.
ISBN
0-9583647-0-2
9 780958 364706
.,
.".,..
The Human Extremities: Mechanical Diagnosis and Therapy
Ro bin McKenzie CNZM, OBE, FCSP
(Hon), FNZSP (Hon), Dip MT
Stephen May MA, MCSP, Dip MDT, MSc
Spinal Publications New Zealand Ltd
The Human Extremities Mechanical Diagnosis and Therapy First published in August 2000 by Spinal Publications New Zealand Ltd
PO Box 93, Waikanae, Wellington, New Zealand Fax 64 4 293-2897 Email:
[email protected]
© Robin McKenzie 2000 All rights reserved. No part of this publication may be reproduced, stored in a retneval system, or transmitted in any form or by any means,
electronic, mechanical, including photocopying, recording or otherwise, without the prior written permission of the copyright holder. ISBN 0-9583647-0-2
Design by Next Communications Edited by Jan McKenzie and Writers' Ink Photography by Stedman Photographics Printed by Astra Print, Wellington, New Zealand
'r '
Dedication To my dear wife Joy:
ivl
Acknowledgments
I wo u l d like to acknowledge the very great contribution made by my friend and colleague Stephen May, MA, MCSp, Dip MDT, MSc, without whose assistance this book would ne ve r have been published Mr May has created order out of chaos and provided this text with
a
credibility that I hope will help change the mode of physiotherapy management of musculoskeletal disorders worlclwide. I would also like to thank
my daughter, Jan, who organised and
coordinated the various specialists required to successfully complete a project such as this. I thank her for her patience and dedication.
I must also acknowledge the assistance of the many faculty members of the McKenzie I n s t i tu te International for their helpful
c o m m e n ts
and criticism of the original text. Robin McKenzie
For their helpful suggestions and comments concerning grammar and contents, I must thank Kenneth May and Julie Shepherd.
Stephen May
Iv
About the Authors
Robin McKenzie was born in Auckland, New Zealand, in 1931 and g radu ated from the New Zeal and School of Physiother apy in 1952. He commenced priv ate practice in vVellington New Zeal an d in 1953, ,
,
specialising in the d ia gn osi s and treatment of spi nal diso rde r s .
During the 1960s, Robin M cK enzi e developed new conce pts of diagnosis and t r eatment derived from
a
system atic analysis of patients
with both acute and chronic back problems This system is now .
p r actise d g lob a lly by sp eci a lists in physiothe r apy, medicine and chiropractic
.
The success o[ the McKenzie concepts of dia gn osis and trea tme nt [or spinal problems has attracted interest from researchers worldwide.
The imp or tance of the di agn ostic system is now reco gn i sed and the extenl of the therapeutic e ffi cacy of the McKenzie method is su bj ect to ongO ing i nv estiga ti o n
.
Robin Mc Ke n z ie is an Honorary Life Member of the Ameri c an Phy sical Therapy As socia t i o n 'in recogn i tion of d Istingui s hed and meritorious service to the art and sci ence of physica l therapy and to the welfare
of mankind'. He is a m ember of the I ntern a tion al Society for the St u dy of the Lumbar Spine, a F el low of the American Back SOC iety
,
an H ono r ary Fellow of the New Zealand S ocie ty of Physiotherapists,
an Honorary L i fe Member of the N ew Ze ala nd M a nipu l a ti ve Therapists Associa ti o n and an Hon o rary Fellow of the Chartered ,
SOCiety of P hys iothe r apis ts in the U nited Kingdom. In the 1990 Queen's Birthday Honours, he was made an Officer of the Most
Excellent Order of the British Empire
In 1993 he received an
H o nor a ry Doctorate from the Russian Academy of Medical Sci ence s. In the 2000 New Ye ar s Honours List, Her M aj est y the Queen '
ap poin ted Robin Mc Kenz ie as a Co mp ani o n of the New Zealand Order of Merit. Robin McKenzie has au th ored four books
Treat Your Own Bach;
Treat YOL!r Own Neck; The Lumbar Spine: Mechanica l Diagnosis and Therapy; and The Cervical a nd Thoracic Spine: Mechanical Diagnosis and Therapy. With the p ub l ic a ti on of The Human Extremities. Mechanical Diagnosis and Therapy, Ro b in McKenzie, in collaboration
\vith Stephen May, describes the application of his methods for the management of musculoskeletal disorders in general As with his
publications dealing with spine-related problems, the emphasis in this text is directed at providing self-treatment strategies for pain and disability among the general population Stephen May was born in Kent, England, in 1958. He did his physiotherapy training in Leeds and graduated in 1990. Since
qualifying as a physiotherapist, Stephen has worked in the National Health Service in England. For the last eight years thIs has been in Primary Care.
Early on he developed a passionate interest in musculoskeletal physiotherapy which ensured he was a keen consumer of the research evidence. In 1995 Stephen successfully completed the McKenzie Diploma programme and in 1998 an MSc in Health Services Research and Technology Assessment. Stephen believes strongly that practice must be shaped by the evidence and that self-management concepts are the future of ph ySiothe rapy.
IVii
Contents
Introduction CHAPTER ONE
.................. 1
Muscul oskeletal Problems
.............. ... .... 7
Introduction
.............. 7
Prevalence
.............. .... 7
Health care
..................... ...................... ..
The site of the problems
........ ..... 10
..................................... 12
Natural history and clinical course
.
............. 14
Systematic reviews of commonly used treatments The problem of diagnosis
..........
.............. .... 16
.... 18
.
Conclusions
CHAPTER TWO
......... 20
Soft Tissue Properties
........... 21
Introduction
....... ......... ................. .. 21
Tissue injury
... 21
Recovery following trauma Inflammation
..... 2 2
Tissue repair Remodelling
21
. .
...... . . . .
. . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . .
. . . . . .
......... .. 22
. . . . . . . . . . .
.
.
.
.
.
Failure to remodel repair tissue
. . .
.
Degenerated tissue in which healing is suspended
23
. 26 . .
... 27
The effects of stress deprivation and exercise on connective tissue
.....................
. ... 28
.
Factors restricting a normal return to [unction
.30
Cumulative postural stresses on musculoskeletal tissue
.... 32
Contractile tissue loading Clinical im plications
...............................
. . . . . .
32
. . .
37
35
.
Sir Astley Cooper's engravings
CHAPTER THREE
Pain
.
Introduction Pain and nociception
59 59
. .
... 59
Sources of pain
. .
Activation of nociceptors
..
. . . . .
61
......
.60
Differentiating between chemical and mechanical pain
.63
. . . . . . . . . . . . . . . .
Constant pain - chemical cause (Constant Chemical Irritation)
......... ............
..63
Cause and onset
63
Behaviour of pain
. . . .
64
Key factors in the identification of pain of an inj1ammatory nature . . . . ..... . " ...................................... 66 .
.
viii
I Stage and status of disorder
....66
Constant pain - mechanical cause (Constant Tissue .. ........... .67
De fo rmat i on) Cause and onset
.
Behaviour of pain
. . . . . .
.
. . . . . . .
. . . . ......
.
..... ....... 67
........... ...... 68
Key factors in identifying constant pain of mechanical origin
69
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Intennittent pain - mechanical cause (Intennittent Tissue Deformation)
.. .
.
.
.
.
. . .
.
. .
.
.. .... . . .
.
.
. . . . .
.
. . . . . . .
. . .. .
.
. . .
. .. . 69 .69
Behaviour of pain -
.
normal tissue
Abnormal tissue
............................
................................................
...................................................
.
70 70
.... 71 72
..
. . . . . . . . . . . .
. . .
.. . .
.
.
.
.
. ...... .......... . 73
. .
. .
. . . .. .. .. .
.
.
.
.
.
.
.
. . 75 . .
. . .. 79 . .
Introduction
.
...............
.
.
.
.
............ .. .
. ... .
............
.
The postural synd ro me
...
The d ysfu n cti o n s yndrom e
..
.
. ....... 7 9
....
... 79 . . 79
The role of diagnosis in musculoskeletal problems
. .
... .
.
. ......... 81
. ......... ... ........
.82 ..... 82
. ........
83
. .................. ..
The deran ge men t syndrome Non-mechanical conditions
......
.... 85
Acute pain
........... 85
Chronic pain
.
Conclusion
History
..
. . . . .
. 86 .
.. .................
Int ro d uc tion
...... 89
Aims of history-taking
...
The interview
........ . ...... .
90
............ 91
Age
. .
Work and leisure activities Functlonal disability
.
.... 77
Mechanical Diagnosis
Making a non-specific d i agnosi s
.
...............
the state of the tissues
The medical model
CHAPTER FIVE
.
..... 74 .
Chronic pain states
CHAPTER FOUR
.
.
.
Derangement
-
.
.
Failure to remodel repair tissue
Conclusion
.
of mechanical
Key factors in identifying intermittent pa i n origin
. .
...............
Cause and onset
Postural pains
.
...........
Where is the present pain?
. 91 .
.... 91 .
...... 91 92
. " .................... " .... "" 92
How long has the pain been present?
.
Did the pain commence following injury!
"
"" . .." .." ... 94 "
. ..
Did the pain commence for no apparent reason?
.. . .
. . .
.
.
.
. . .
Is the p rob l em improving, worsening or unchanging! Is the pain constant?
.
. . . "",, ...... """"".,,....... . .
. .
. 97
.
Is the pain intennittent?
" .. . .
. . . .
... .
.
95
. 96
, ,"" "
" .
98
What activities produce or worsen the pain! What activities stop or reduce the pain? Does it remain worse
" ........""........." ... "",,.......
or better afterwards?
."."". 98
Does continued use of the affected area increase, decrease or have no effect on your pain!
... "....,," .................. ".,,"" 99 . .
Do Y0Lt have pain if the limb or part is relaxed at rest?
.
. . .
" 100
Can you find a position that stops your pain? . . .. " ........""",,.. . ................. 100
If so, please describe
.
.
.
Do you get better or worse as the day progresses? Is it a pro b l e m at night?
."".........." .....".. "..........."" ....." 100
. . .
Have you had any previous treatment for this episode? Have YOll ever had this problem before?
.
. .
.
.
... . .
.
. . .. ... . . .
. . . . . .
. . . . . . .
. .
.
. . . . . .
. ... . 101 .
.
. . . . .
.
. .
.
.
."....... 102
. . .. ... . .
.
.
. . .
.. ... .
Have you been x-rayed for this problem?
.
102
.. 103
. . . . . . . . . .
Conclusion
CHAPTER SIX
.
. .." .......... . ... 10 1
Are you taking any medication for this problem? Is your general health good or poor?
. 10 1
......""". . ,, ..."" 10 1
"
What treatment was given for that problem? Do you get back or neck pain?
. . . .
........ . .. 103
Physical Examination .......
Introduction
.............. . ..... 105 .
. . . "
Aims of physical examination
...
. .
... .
. ... lOS
.
...................... .
.
.
.
.. . .. . .
..... ......
Observmion
. .
. . .
....
. 10 6 107
Mechanical evaluation
.107
Role of palpation
. 107 ..... 108
Use of the assessment form
Active movement
.................................... 109
Active movement summary
....... "" .... ....."" ....... " "
... " ... "......... ...........
Passive movement
.
. . . .
Resisted tests sllmmary
.. .
III
" ......................" ...,," 112
Passive movement with overpressure
" ..... " ..... "" 114
Passive movement with overpressure summary . . . . . . .
...........
.. "" .. " ................. " "... "" .. "., 112
Passive movement summmy
Resisted tests
..... .. 111
.. " ..... . ......... ".""",, ............... 1 14
.
.
.
. . .
.. .
Repeated movement or loading
.
. . . . . .
.. .
. . . . .
. ..
. . .
.
. . . .
"...." ........... 11S
. . . " . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
lIS
xl Repeated movement in the postural syndrome
. .. . . . ".". 118
.
.
Repeated movement in the dysfunction syndrome
. .
... . . .... . .. 118 .
Repeated movement in the derangement s y n d rom e SummCllY
.............. ..............
Neurological examination
.
. . . . .
............ 11 8
119
.
. . . . . .
. . . . . .
.. .
. . .
.
.
.
...
.
.. . . .
.
.
..119
.
Co n clus i ons
...... 120
I n c o n c lu siv e res u l ts
CHAPTER SEVEN
.121
Assessment of Symptomatic and lVIechanical Presentations and Responses Introduction
. . . . . . . . .
. . . . . . . . . . . . . .
. . . . . . .
..
. . . . .
.
.
.
.
.
.
.
.
.
.... 123
Mechanical presentation and its assessment
. . .
Assessment of the symptomatic presentation
Chronic pa in
CHAPTER EIGHT
. . .
.. . ..... .. .............
.
.
.
.
.
.
.
.
..... 133 .
. . . . .
.
.
.
.
.
1 33
............. ..... l33
Education com p onen t of management me
chan i c a l therapy co mpo n en t
..... 137
Compliance or therapeutic alliance:> To treat or not to treat:>
.
.
.
.
.
.
.
Condition improving
.
. .
.
.
. 138
.
.
139
.... 140
Conditi on unchanging
141
Co nditio n worsening Conclusions
Management and Sel f-Treatment
.
.
.
142
.
.
.
144
..... . ....... 14'5
lntroduction
.... l45
Normal tissues, abnormal stresses - Postural Syndrome
. . .
EdLtwtion towards self-management
.
Self-treatment procedures required Acut e p resentati o ns
.
.
.
. .
.
. . .
. . . .. .
.
. . . .
Sub-acute presentations
. . .. .
.
. .
".
Post-trauma - tissue h ea li ng
.
. .. .
.
.
.
.
""".,,
.
.
147
.. 148
149
.
. .
. . . . . .
Education towards self-management Self-treatment procedures
.
... 149
. ..
" .,
.
146
.. .... l49
tissue injury
. . , .. .
.. . . . . ... . . .. .
.. .... ....... .. ...... .... ..
Traumatic onset Management
128
. .. 130
..........
.
lntroduction
CHAPTER NINE
125
.... 126
Patient Management
Active
.
............... 126
Use of symptom responses to determine loading st rategIe s
. .
. 123
. .... 123
.
Symp tomat ic presentation
Review process
.
.
.
.
. .
.
,
.... 151 . . 151 151 ". 152
Ixi Ch roni c presentations
"
.
" ..... ....... 154
Late traumatic p r e se ntati on s - abnormal tissue
. 154
Late insidious onset presentations - abnormal tissue
.154
Intra-articular derangements
. . .
.
. . . . .
..
. . . . .
. ..... .
..
.
.... .
. . .
....
. . . . .
155
Chronic pain states - abnormal tissue/abnormal
response
.........................................
..155
Abnormal tissue, normal stresses - Dysfunction Syndrome
.. ..
Articular dysfunction
......... ..... .... 156
Education towards self-management
.... . . . .
. .
.
. . .. .
.. .
.
. ..
. .
.
..
.
. . . .
.. . . .
.
...
156
157
.
Self-treatment procedures reqUired to remodel articular dysfunction
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.. . .
Musculotendonous or contractile dysfunction Education towards self-management
158
. . . . . . . . . . . . . . . . . . . . . . . .
.
.
.
.
. . . . . . . . . . . . . .
... .
.
.
.
.
.
. .
. ..
.
161
.
162
. . . .
Self-treatment procedures requi red to remodel musculotendonous dysfunction Treatment
.
. .. . .
.
. .
.
...
.
. . .. . . . . . .
. . .
.. . .
. .
162
. . . . . . . . . . . . . . . . . . . . . . .
......................................... 168
Articular Derangement Syndrome
....
Education ill self-management
.
.
. .. . .. .
....
.
... . . .. .
. . .
....
. . .
.
.
. . . .
.
. . .
.
.
...
..
. .
.
. . .
169
. . . .
171
. . . . .
Self-treatment procedu res required to reduce il1temal ........................................................... 172
derangement Chronic pain states Management
.
. . . .
.
.
. .
.
.
.
. . . . . . . . . . .
.
.
. .
. . . .
.
.
. .
............................ ............. . 182
. . . . . . . . . . . .
. . .
.
. . . .
. . . . . .
.
. . .
.
. . . . . . . . . .
.
Therapist te c hniques and passive modal it ies Clinician p rocedure s
....... 186
............................ ..... 186
Common Disorders Introduction
... 185
...............................................
Passive modalities
CHAPTER TEN
184
. . .
. .
.
. . .
. .
.
.
. . .
. . . . . .
.
.
. . . .
.. 190 .
................................................ .................. 190
The spine and peripheral Joint problems Rotator cuff tendonitis
...... .... .
. . .
..... .....
... 191
. ............................... ..... 193
Natural history and clinical course of rotat o r cu rf tendonitis
. .... .. . .
Management a n d self-treatment exercises Capsul it is of the gleno-humeral joint Natural history Management
(, fro z en
. . .
.
...... 196
...................... .. 197
shoulder')
... 204
... ............................ ...... 205 .205
Self-treatment exercises
..... 206
Clinician mobilisations
............... . 209
Late r a l e pic on dyl itis ('tennis elbow')
..... 215
xiii The natural history and clinical course of lateral epicondylitis
... 216
Self-treatment exercises
.....216
'Pseudo' tennis elbow or elbow derangement Self-management exercises
... 218
............
Carpal Tunnel Syndrome
..218
.
....... .
..
.
.
. . . .
... 224
.
Natural history
..226
.
Management
.
.
.
..
226
. . . . . .
Tenosynovitis - de Quervain's Syndrome, ('trigger finger')
228
Management
..... 228
Dupuytren's Contracture
... ........... .... . ............. 231
Management
............
. ..232
Bursitis Overuse injuries
232 . . . . .
.
. .
. . .. . .
.
....233
. . . . . . . . . . .
Management of overuse injuries
...237
'Groin strain' or adductor strain
...238
Management and self-treatment exercises
. ............240
Achilles' tendon injuries
241
Management and self-treatment exercises
................. .243
Patellofemoral joint pain
...... .24 5
Clinical presentation
............... ............. .. .
.. .....248
Natural history
........ 249
Management
.
... ....... ......
Mechanical diagnosis and therapy
............250
........ ........
Sell-treatment exercises Degenerative joint conditions losteoarthritis
..
.
.
.
.
.
.
.
.
.
Lateral ankle sprains
. . .
. . . . .
. . .. .
.
.. . . ...... .
.
.
.
... ..
. .
. . . . . . . . . .
. . . . . . . .
.
.
.
.
.
.
.
.
.
. 257
. .260
.... ........265
Management of ligament ruptures and sprains . . . . . . . . . . .
.
.
.....
........... .
.
. . 255
.
Management of degenerative joint condiLions Self-management exercises
Self-management
. .2 51
.........2 52
........ 265
. . . . . . . . . . . . . . . . . .
. . . . . . . .
267
CHAPTE R ELEVEN Cl inical Reasoning
............... . ........... .
Introduction
.....
.... ..... . 273
......... .....
Elements that inform the process of clinical reasoning ..
Data-gathering Knowledge base Clinical experience
.
.
. . .
. . . . .
.
.
.
.
.
.
, ... ....
.
.
Errors in clinical reasoning
,
.
.
.
.
. .. . .
.
. . .
. . ..
.............
.
.
.
.
.
. . .
.
.
.
.
.
. . . . . .
............
274
.
.
280
. ... 280
............ .
An example of clinical reasoning
.
.275
.
..................
.
. ..., ...... 27 4
. .. . .................
Cognition and meta-cognition
.
273
...... 281 .
.
.
. . . . . .
.
.
.
. .
.
..
.
...282
Ixiii .... 282
History-taking Physical examination
........ 285
Education anel active mechanical therapy
..... 286
Conclusion
.............. ...... 288
R eferences
. . . . . . .
. . . . . . .
. .
289
.311
Glossary of Terms Index
. . . . . . . . . .
..........
.. .................... ... 315
xiv
I
List of Figures
1.1
Chronic conditions in the general populaLion. Rate of reporting selected conditions per 1,000 adults
1.2
. .
.................
............
. .............. 8
. . ... 9 .
.
. .
. .
Reported prevalence in the general population o[joint problems by men and women
1.5
.......... 9
Musculoskeletal symptoms in those attending primary care
1.6
11
Distribution of different locations of musculoskeletal symptoms in the general population
1.7
. .
. . . . . . . .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
. . 13
Distribution of different locations of musculoskeletal symptoms in those visiting primary care
2.1
.
Reported prevalence in the general population of certain joint problems by age groups
1 .4
. 8
Prevalence of joint problems in the general population by age range
1.3
.
..... 14
Time course of cellular activity following tissue injury
.
. 26
Sir Astley Cooper engravings Plate II
....
. ..... ..... .
.. .... ....
. .. ........ 38
Plate III
.. .... 40
Plate IV
......... 42
Plate V
44
Plate VI
.
Plate XXII
..... .............. .
Plate fu'ZllI Plate fuY...V
46
. . . . . .
. . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . .
. . .
.
.
.
.. 48 .
.
. . . . . . . . . . . .
.
.
.
.
.
.
.
.
.
.
.
.
Plate XXVll
. .
.............. .. 104
The McKenzie Institute Peripheral Assessment sheet physical examination
9.1
10 1
56
The McKenzie Institute Peripheral Assessment sheet history-gathering
6.1
52
. '54
Plate XXVlll
5.1
50
. ..
Assessment sheet- knee derangement
. .. .. 122 ...... 180
Assessment sheet - rotator cuff suprinatus dysfunction
.
.
.
.
.
.
.
... .202
. . . . . . .
10.2
Assessment sheet- capsulitis early stage
10.3
Assessment sheet- frozen shoulder late stage
.
.
.
.
. .
.
. . . . . .
.
.
.
. . .
211
213
Ixv 10.4
Assessment sheet - tennis elbow
10.5
Assessment sheet - anterior knee pain
10.6
Assessment sheet - hip j oint OA
10.7
Assessment sheet - ankle inversion sprain
Photos 1-118
. . . . . .
.
. . . . . . . . . . . . . . . . . . . . . . . . . .
222
........................ 253
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
153
-
263 270 268
List of Tables
1.1
Prevalence of musculoskeletal problems by site
...... 12
in general population
1.2
Prevalence of musculoskeletal problems in those who seek treatment
................ 13
1.3
Diagnosis given by clinicians for shoulder conditions
2.1
Matching the stage of the condition to management
3.1
The state of the tissues
61
Description of a shoulder joint dysfunction
6.2
Directional preference
71
Disability questionnaires
7.2
Traffic Light Guide
8.1
Classification chart
. . . . . . . . . . .
. .
. 18
. . 25 .
. . . .
.
.
77
...... 109
.. .. ...... 119 ... 125 .
. 127 . .
..... 144
INTRODUCTION
Introduction
M echanica l disorders a ffecti ng the soft tissues and joints of the human
extremities are encountered d aily by general practice p hys icia ns
,
physiOlherapists, chiropractors, osteopat hs and a myriad of alternative health care providers. vVhether the prob lems arise subsequent to injury or from inflammatory or degenerative processes, the
consequences are pain, stiffness and limitation of function or activity, or all of these. The duration of impairment, pain or di sability can vary from a few d ays in the case of minor injury to months or even years in some conditions fortunately a ll hving bodies, human and animal, have remarkable c apac i ty to heal and repair. A nimals in the wild can recover and survive from a p paren tl y catastrophic i njury Skeletal remains of p rehistoric
man
show similar ability to survive
b oth injury and degeneration The natural healing process h as allowed living things to recover from all but fatal injury The remodeling of soft tissue and bone alike is evidence of the body's inherent capaci ty to repair, adapt and survive
.
Our ancient fore b ea rs had no knowledge of the mechanism of hea ling or medication to relieve pain. They must have d iscovered in very
early times, however, that failure to restore activity levels mean t certain rapid decline and eventu al death. F ortunate ly mankind survived, and did so in those e a rl y times without the expertise of numerous therapists and physicians. A century ago, only those suffering severe injury causing fracture or
dislocation sought the services of a phy sician E ve ryday problems such as sciatica, l u m b ago tennis elbow, hou se m aid's knee and wry ,
neck were mos t o ften manage d with home remedies or by bonesetters.
A 'hot iron on vinega r and brown paper' or 'stinging nettle' were comnlOnly applied as counter-irritants to painful di sorders until the
nat ura l healing process brought eventual reli ef People in pain went about theil- daily tasks. Minor aches and pains were frequently disregarded, considered trivial and were viewed as another of life's hurdles either to overcome or to bear. They pu t up with the pain of repetitive strain and occupational over use until their structures adap ted At the beginning of t h is century, to do otherwise would have meant starvati on
.
11
211
NTRODUCTION
THE HUMAN
EXTREMITIES: MECHANICAL DIAGI'\IOSIS
& THERArY
The chemical and mechanical tools and the economic capacity that allow us to apply many diverse treatments to musculoskeletal disorders for the alleviation of pain and disability have only been available in comparatively recent times. Improved social support structures now sanction sick leave for workers with m uscu loskeleta] problems. These conditions have created an extremely costly situation for society In the Western world in modern times, the family medical practi tioner, the ph ysiotherapist, naturopath, acupuncturist, chiropractor, osteopath and others are consulted to provide relief and reassurance to those with injuries and aches and pains thal long ago would have been silemly borne until nature had her way. In modern times a common response to musculoskeletal complaints is to seek help from one or many of those offering a solution. So successful have modern health care providers been in creating patient dependency on therapy and therapists that the advice usually proffered by one layman to another complaining of pain is routine 'you had betler go and see someone about thall' There exists in Western populations a widespread belief that for healing to occur it is essential to have some son of treatmen l. Unfortunately, clinicians in training are commonly led to the same belief by their teachers. The desire of the public to receive treatment for many minor injuries or pains has led to an explosion in the demand for services and expenditure within health services worldwide. This demand has occurred especially in the field of phYSiotherapy services. As an example, in 1953, in the city of Wellington, New Zealand there
were
seven physiotherapists serving a population of
138,000 people In 1998, 61 clinics served
a
popu lalion of 1 S9 ,000,
a ratio of one therapist for every 2,600 people. There is no evidence to suggest that the prevalence of musculoskeletal problems in the community has escalated in a similar way The increase in consumption of therapy services seems hard to justify and more difficult to explain. Only a small perc e ntage of musculoskelelal injuries actually require profeSSional assistance during the period of healing and repair Patients may need education and advice about the most effective way or returning to full [unction following soft tissue trauma, but offering treatment of dubious efficacy only detracts from the imporlance of the patient's role in this recovery
I NTRO DUCT I O N
I N T RO D U C T I O N
Patie n ts w ith dege n erative J oint disease and chroni c m u s c u l o s k e l e t a l p ro b l e ms certainly req uire educa t i o n in se l f-manageme n t , b u t i t is hig h l y unl i ke l y t hat t h e y re q u i re traditional modal ity - b ased passive physi o the ra p y Hea l th c a re providers allied to m e d icine have t w o gre a t persisting han d ica ps T he firs t is t h e lack o f un d ersta nd i ng o f the meaning and si gni fic a n ce o f t he p h ra se ' n a t u ral history ' . The term is rarely pa rt o f the voca bu l a ry o f o u r teachers a n d i s h ard to fi n d i n text b o o ks used in physi othe ra py, c h i ro practic and osteo p athic scho ols of e d u c a ti o n . Ye t i t i s u p o n t he na t u r a l histo ry of mechanical d iso rd ers t h a t so many of u s re l y For our su rvival as health care p ro fessio nals . The second great handica p is t he inab i lity o r rel u c tance of those in cli n ica l p ra c t i c e to a c k n o wledge d e feat. There is a gene ral t e n de ncy
by cl inicians [ 0 persi s t ,,,v i th treatmen t l o ng a fter a l l available methods have been fou n d wanting. There seems to be a reluctance amo ng heal th care p ro v ide rs (0 a c k n o w led g e their limitati o ns . The res u l t i s a co n t in u in g sea rch fo r a n elusive p a n a cea - a ne w techniqu e o f
man i pulation o r a n e w fo r m o f e l e c tro therapy that will so lve the p ro b l e m w h e n a l l e l se has fa i led. It is n ot ge ne r a ll y recogn ised tha t the re is l i ttle sci e n t i fic e v i d ence su p p o rt i ng the use of any of the current phYS i o t herapy m o dalities for the t rea t m en t of muscu l oskeleta l disorders . The re is , ho wever, am ple evide n ce tha t the a p p l ica t i o n o f m o ve ment and the rep e a t e d and prolonge d fu n c t i o n i n g o f a l l structures a ffected b y injUly pro vides the best sti m u lus for repair a n d the best environment
in
w h ich to
achieve fu ll recove ry of fu nction a n d p a i n - fre e status. W h ere s i gni fi c a n t
inj u r y c a u s e s
t h e p a t i e n t p e rs i s t i ng p a i n ,
impa irmen t o f funct ion and re d u c e d mobili ty, phYSi othe rapy by way of e d ucation and su pervision may b e indicate d . Physiothera py canno t acce le rate healing , b u t education a n d supe rvision can ensure that healing is not d isru pted and that the environment fo r re c o v e ry is optimal . T h e main [u n c tion of the physiotherapist o f the fu t u re w i l l be t h e e d u c a ti o n a n d e nlightenment o f
the inj u red and i gn orant .
P a t ient education is o n e o f t h e mai n t h e mes o f this tex t . Patients
m us t be p ro v id e d w i th sound explanatio ns and sho uld comprehend the n eed t o m a intain the c o rre c t envi ronment fo r m a naging the i r p rob lem. It i s a lso necessary fo r the patient to u nderstand that the
13
4/ 1
N T R O D U CT I O N
TH E
H U MA N E X T R E M I T I E S :
M EC H AN I CA L
D I AG N O S I S
&
T H E RA I'Y
recovery of fu nc ti o n can only com mence fo l l o wi ng a d e qu a te healing a nd repair, and requires an ap p ro p ria te reha bilitati o n p rocess . These p ro cesses may take time , but rec ove ry is i mposs i b l e wi tho u t t h e p a tien t s a c tive in vo lvemen t . '
This text does n o t a t temp t to p ro v i d e the rea d e r w i t h a d e ta ile d description o f diagnos t ic proce d u res usu a l l y e x pe cted i n a book a b o u t muscu l oskeletal d iso rd ers o f the e x t re mi t ies . I no lon ge r b e l i e v e t h a t the p recise i d e n t i ficatton o f the stllJ c t u re i n v o l ve d i s n ecessa ry o r a p r e re q u isi t e fo r the p rescri p tion and s a fe de l i v e ry o f a p p ro p ri a te mecha nical th e ra p e u t i c i n t e rventio ns ; n o r d o I be l ieve it is a l ways p o ss i b l e to make such an i d en t i fica tio n . irres p e c t ive o f t h e stru c t u re in volved , ulti matel y the mechan i c a l the ra p e u tiC stra tegy is d eterm ined s o le ly from the res p o nses obtained fro m tissue l o adi n g a n d the e ffec t t ha t l o a di ng h a s o n symp to m a to l ogy T h i s b o o k is not i n te nd e d t o fi l l a g a p for those in search o f an a d d i t i o nal t e ch n i q u e o f m o b i l i s a t i o n o r mani pu la ti on
.
This b o o k is written to e n c o u rage a p p ro p riate heal t h c a re pro fe s s i o na ls t o p ro v id e s o u n d and e ffe c t ive sel f-ma nage m e n t (o r t h e i r pa tien ts The a d vice p rov id ed is a imed a t all o w in g t h e p a t i e n t t o .
take res p onsi b ility fo r h is o r her o wn re c ove ry I t i s h o p ed t ha t i n depa rting fro m the u s u a l ' hands on' p a thway s o d e a r to t h e h e a rts o f many cl inici ans , the e mphaS iS will s h i ft fro m p a t i e nt d e p e n d e ncy o n therapy t o p a tien t i n d ependence . The truth is t ha t t h e v a s t n u m be r o f treatments d elivere d b y h e a l th ca re providers fo r t he a l l e v i a t i o n o f muscu loske l e ta l aches and pains are usu a l l y u nn ecessa ry ; cena i n l y their e ffe c t i v e n e s s i s un p ro v e n
.
E v e n t u a l l y, a ll p h YSio the r a p i s t s
i n v o l ve d i n the fie l d o f o r t ho p a e d i c m ed i c i n e and th e ra py m u s t p ro v i d e t h e e du c a t i o n t h a t w i l l e n a b l e t h e p a t i e n t t o p ra c t i c e '
au to therapy . '
The m a i n themes to uched on h e re a re d eve l o p ed thro u gh o u t the b o o k . The prevale nce o f musculoske l e t a l d iseases , t he l a rge nu mbers of p e o p l e w h o have p ers i s ten t pro blems a nd the lack o f e fficacy o f many commonly used tre a tments are examin e d . The h ea ling process of s o ft tiss ue inj u ries , the mechanic a l , in n a mma to ry and c h ron i c pain m e c h a n isms , and the m e ch a n i c a l s yn d ro me s o [ t h e M c K e n z i e ap pro ach as re lated to the p erip he ra l j oints are d escribed l n fo m1ation o n how t o gather data about pa tie nt p roble ms assess cha n ge s a n d ,
manage di ffe re n t pa tien t conchtion s i s a lso p resented . Some c o m m o n d i s o r d e rs are d escrib e d and a ppro p ri a t e s e l f- t re a t me n t s t rategies are
I N T RO D LJ C T t O N
recommend ed . I t i s hoped tha t thi s text w i l l s u p po r t t h ose c lini c i a n s
who are p e rple x e d by t h e fa ilure o f many interven t i o n s to ' c u r e ' their p a tie n ts' p rob l e m s , a n e! w h o s e e k e n d o rseme nt for an a p p roach th a t de m a n ds p a t i e n t i nv o lvement a s t h e o n l y l ogica l w a y forward for t h e physi o t he ra p y p ro bsi o n .
I N T R O D LJ CT t O N
15
S I I N T RO D U CT I O N
T H E H U MA N EXTRE M I T I E S : M E C HAN I CAL D I AG N O S I S & TH E RAPY
C H A PTE RON E
1: Musculoskeletal Problems
Introduction
This [irsL chapter is intended to give a brief overview of the problem of musculoskelelal pain in the general population. Health problems
are located in broad contexts and should not be considered only through the narrow focus of the clinic. If we know more about the prevalence, the natural history, and the effect of treatment upon a conditio n, then our understanding of a clinical problem is considerably improved T he size of the problem, its persistence and the health care services' ability to deal with it also have repercussions upon management Diagnosis in musculoskeletal medicine is in its infancy. Wit h i n spinal prob !ems speCific d iagn oses have been replaced by broad, non -specifie
categories (Spitzer 1987; Rosen et al. 1994) In peripheral problems, specilic diagnostic criteria are used more widely with an underlying assumpLion of reliability, which is, however, barely endorsed by the studies available. This chapter will also look briefly at some of the issues surrounding the problem of making a diagnosis. The implicaLions that Lhese issues have upon the management of musculoskeletal problems will be discussed. Prevalence
Musculoskelewl conditions of al l types are extremely common
in
Lhe general population They are frequently found in population surveys when individuals not receiving treatment are asked abouL problems. These studies give a re a sonab ly accurate picture of the extent of in [ he UK
a
particular problem in the community. Population surveys
show that musculoskeletal problems, spinal and non-spinal,
are the most frequently reported long-standing illness in all age groups (Bennett
et
al. 1995)
There is a linear increase in these conditions with age. Less th an 10% of Lhose under 34 are affected, rising to 32 49% of those over 75 (Bennett eL al. 1995; Badley and Tennant 1992) After 45 years of age -
over 10% of the population are affected by multiple jOint problems.
Difficulty WiLh daily functions and lack of independence, as a consequence or these problems, rise linearly to ab o u t 50% in those over
H'J
(Badley and Tenna11l 1992)
17
81 C1-1 Al'TE RON E
THE HUMAN
EXTREMJTlES:
Figure 1.1
Chronic conditions in the gene ra l population. Rate of
MECIIANICAL DIAGNOSIS & Tt-IERArY
reporting selected conditions per 1,000 adults. UK
(Bennett
et al. 1995). 160 140 120
° °
D.
100
�
so
" "" ;; �
60 40 20 0 HC;.1r[ & CirclIlatory problems
Musculoskelelal
prohlems
Rcspirillory prohlems
Digc.::.Livl' system prohlems
Site of condition
Figure 1.2
Prevalence
by
of joint problems in
age range. UK
the general population
(Badley and Tennant 1992).
Ml sO u u
5
-;;; >
�
0..
?f!-
40 }O
1·2
§:']
multiple
r;
20 ](1
i!il
t-----,
J6·24
25·}4
',)·44
'IS-54 Age group
Problems
were
i ,·(1·1
65-/4
75·84
,l.J'
(in decades)
evenly divided between back problems, 'Olher bone
and Joint problems', and 'arthritis and rheumatism' (BenneLt 1995) While the prevalence of spinal problems reached
a
et
plateau
al. in
those older than 55, non-spinal problems continued to increase after this age Musculoskeletal problems are more common in women aL all ages. Surveys of general populations in oLher countries give Similarly significant proportions thaL repon all types of musculoskeleLal symptoms. In Denmark, long-standing musculoskeletal problems are
p re valent in 13% of the population, and make up 30°/r, of all chronic illness (Bredkper 1991) They constitute the large':>t cause of chronic disease in Finland (Sievers and Klaukka 1991). In the US the prevalence rate of musculoskeletal illness is 30% (Cunningham and Kelsey 1984) and in Canada 16(X) (Lee et al. 1985) In Sweden
CHAPTER ON E
MUSCULOSKELETAL PRORLEMS
Figure 1.3
Reported prevalence in the general population of certain joint problems by age groups. UK (Badley and Tennant
32 30 2H 26
,y �. E 0
� �
-
24 -
22
-
-+-
"nklc
- .--
hip
-
:& -
/ /
"houlder
/
- - x- - hand - *"
- knee
"
-'-[ow back
25·3-1
1992).
-1)·)-1
35·4-1
Age group
55·6-1
65·7i
(in decades)
75·84
85+
10 - 20l)6 of the sample population reported obvious musculoskeletal
pain, most with pain persisting for more than six months (Brattberg 1989), and in Lhose over 45 years of age, 35% reported long-lasting JOint complaints (Larsson et al. 1991) There is some evidence of an increase in reponing of musculoskeletal problems and consequent
health service use in Sweden
in the last few decades (Sievers and
Klaukka 1991; Slalis and Ruusinen 1991) There is some suggestion Lhat social and economic factors, as well as medical ones, playa role in determining wl1ether a person with these symptoms goes on to
develop disability related to their musculoskeletal impairmenL (Cunningham and Kelsey 1984) Reported prevalence in the general population ofjoint problems
Figure 1.4
by men and women. UK (Badley and Tennant
1992).
70 60 50 40
/
,y
. •...... .•.. .... .•...
30
. ..
-+-women
20
- -.- - men
10
0 16·24
3,11
45·54
55·64
hi ;4
Age group
(in decades)
7+85
85+
19
10
I CHArTER ON E
TH E
HUMAN EXTIUMITI ES:
MECHANICAL DIAGNOSIS
& TI-I ERArY
A common musculoskeletal problem is shoulder pain. Populations in Sweden and England who were 50 or older reported painful shoulders in 14 - 34% of the samples investigated (Bergenudd et al. 1988; Allander 1974; Chard
et al.
199 1; Chakravarty and Webley
1990) In a Nigerian village, 14% of a commumty-based sample were found to have shoulder problems (Adebalo and Hazlernan 1992) Across all ages, 7% of the population have been found to have shoulder conditions. This makes it the most frequent musculoskeletal complaint after back and knee problems (Badley and Tennant 1992) Osteoarthritis is the most common sou rce of Joint problems throughout the world. This disease accounts for considerable disability to individuals, as well as a considerable cost in health services to society (Felson 1988; Felson and Zhang 1998) The prevalence of osteoarthritis from the middle years onwards is about 5%, although obviously this increases dramatically with the oldest groups (Petersson 1996; Felson and Zhang 1998) RadiographiC degenerative changes become so common in older age groups that it can be said to be normal These changes are present in the majority of people by 65 (Felson 1988); however, only 30
-
40% of those
with radiographiC changes have symptoms (Felson 1988) The hands, knees and hips are the most common sites of osteoarthritis, in that order (Petersson 1996)
For instance, the prevalence of knee
osteoarthritis reported by several studies ranges from 12
-
38% of
subjects surveyed (Spector and Hart 1992) Osteoarthritis was the diagnOSiS given in about a third of patients attending an orthopaedic outpatient department in the UK (Byles and Ling 1989)
In summary, about a quarter of all populations surveyed have musculoskeletal conditions, including osteoarthritis. This is the figure of those affected in the general community, not those seeking treatment. There is increasing prevalence with age, and women are more at risk than men. Musculoskeletal conditions of all kinds constitute one of the biggest causes of chronic d isease.
Health care The high prevalence rate in the general population is renected in the frequency with which individuals consult meclical pracLitioners with musculoskeletal aches and pains For instance, in the UK, 15% of the population consulted their GP because of a musculoskeletal complaint in 1991 (},/lcCormick et aL 1995)
In three general
CHAPTER ONE
MUSCULOSKELETAL PROBLEMS
practlces, a b ou t 15% of GP consultations related to spi nal and non spi n al Joint and soft tissue problems (Hackett et al. 1993) The consulting raLe was low among Lhose under 44, but then increased sLeadily with age, with rates hi gher among women of all ages. The
most common three groups of pro b lems with roughly equal ,
propomons, related to back pain, arthropathies and 'rheumatic complaints', including otherloinL, muscular and soft tissue problems. Some 5°;(, of general practice consultations are reported to be related to shoulder disorders (van der HeiJden et al. 1997) Two per cent of the total population consulted for tendonitis or bursitis, mostly at the shoulder and elbow (McCormick et al. 1995) In
a
rural F i nnish
popul atio n musculoskeletal problems accounted for 27% of adult ,
visits to their primary care physician, and 21 % of all visits (Rekola et
al. 1993)
Figure 1.5
Musculoskeletal symptoms in those attending primary care. Finland (Re/wia 1993).
TOlal
7634
visilS over 2
weeks
o Palienls with musculoskeletal symptoms
Not everyone consults with these types 01 problems
In
Ch ard s (Chard '
and Hazleman 1987; Chard et al. 1991) surveys of 70-year-olds,
about 25% had shoulder pain O[ the surveys, only 14% and 35%
e spectivel y of those with pain sought medical attention; of these, in
r
one survey, o n ly 40% were gi ve n any form o[ treatment. Frequently patients become disillusioned with health care, and after treatment failure they stop attending (van der Windt et al. 1996; Chakravany and Webley 1990) Musculoskeletal problems constitute an extremely common health p ro bl e m in the community, with the burden being greatest in older
populations. They represent the most common cause of persistent symptoms and functional disability in the general population. They are also a very common reason that people seek health care services.
111
121 CHAPTER. ON E
THE HUMAN EXTRJMITIES: MECHANICAL DIACNOSIS & THERAI'Y
The site of the problems
Clearly musculoskeletal complaints are a common cause of morbidity in
the population at large and represent a large burden LO health care
organisations. In this instance we are concerned specifically wah problems
in
the limbs.
In
the general population the prevalence of
peripheral joint problems is much greater than spinal problems (Badley and Tennant 1992; Cunningham and Kelsey 1984) In surveys in which the site of all disorders has been collected less than 20% report spinal problems, whereas 44
-
49% report pain in the
extremities (Badley and Tennant 1992; Cunningham and Kelsey 1984) Half, or more, have symptoms in more than one site (Larsson et
al. 1991; Cunningham and Kelsey 1984), with the most common
sites affected being the shoulders, hands, knees and hips. Table 1.1
Prevalence of musculoskeletal problems by site in general population
Site oj pain
lumbar
Badley
Cunningham
10%
17%
Larsson
(all spinal)
cervical
6%
shoulder
7%
7%
15%
elbow
3%
4%
6%
wrist
3%
3%
gOAl
hand
7%
7%
15%
hip
5%
8%
13%
knee
10%
13%
17%
ankle
4%
4%
10%
foot
5%
3%
6%
However, 'vvhen it comes [0 those who seek health care services [or musculoskeletal problems, more people WiLh spinal pain appear [0 come forward, as non-spinal joint and soft tissue problems represent about half of the load of musculoskeletal morbidity seen in clinics (Hackett
et
al. 1993; Peters et al. 1994; Hockin and Bannister 1994;
Rekola et al. 1993) Comparing data from different countries suggests that spinal problems
in
the general population represent about 259{)
of musculoskeletal disorders (Cunningham and Kelsey 1984; Badley and Tennant 1992); however, in primary care they constitute nearly half of all musculoskeletal conditions (Rekola
et
al. 1993; Hackett
et
a1. 1993; Peters et al. 1994) In surveys of one GP praC[lce (Hackett
et
al. 1993), one orthopaedic out-patient department (Hockin and
MUSCULOSKELETAL PROBLEMS
Figure 1.6
CHAPTER ONE
Distribution of different locations of musculoskeletal symptoms in the general population. US
(Cunningham and
Kelsey 1984). 20 ,-----IH
-j------
16
c
I-I 12 10 8 b 4
�o0'
Localioll of symptoms
Bannister 1994), both in the UK, and one practice in a rural primary care setting
in
Finland, the average prevalence of problems by site
was as l-ollows Table 1.2
Prevalence of musculoskeletal problems in those who seek treatment
Site
of pain
Hachett
Hochin
Rehola
lumbar spine
30%
35%
18%
cervical spine
15%
12%
20%
shoulder
22%
8%
14%
SOrL lissue inJunes
11%
knee
10%
21 %
ll%
ankle/fool
6%
20%
11%
Lennis/golrer's elbow
4%
4%
2% 11%
wnSl/hand hip
4%
These ligures suggest that peripheral musculoskeletal problems represent at least half of all musculoskeletal conditions seen
in
primary
care and hospital settings, and that the most common sites of peripheral problems that patients seek help for are shoulders, knees and ankles However, they also show that the proportion of different conditions may vary quite considerably in different clinical settings.
113
141 CHAPTER ONE
THE HUMAN EXTREMITIES:
Figure
1. 7
MECIIANICAL DIAGNOSIS
Distribution of
di.fferent
& THERAPY
locations of musculoskeletal
symptoms in those visiting primary care. Finlal1d
et al.
(Re/lOla
1993).
25 ,--
20
15
10
o Neck
Back
Shoulder Ankle & Hand & FOOL \VrisL
Knee
HilJ
Thoracic
llho\\'
Ullin
Localion of symptoms
Natural history and clinical course Although the natural history of musculoskeletal pro blems is
frequently thought to be good and the outlook with tre J t m enL is
often viewed optimistically, the evidence s u gg es t s oLherwise As several of the above studies make clear, large numbers or the population have t h ese conditions for long periods or ti m e (Bennett et
aL 1995; Bred kj aer 1991; Sievers and Klaukka 1991; BraLtberg
al. 1989) Studies show
in c re asin g prevalence
ct
or t h e s e conditions
'vvith age, su ggesti n g that degenerative changes and cumulative trauma
has a role in their aetiology and chronicity (Badle)' and Tennant 1992; Cunningham and Kelsey 1984)
For instance, many studies have found Lhat shoulder pain has pe rsist e d or recurred in at l east 40% of those patienLs studied when
followed up for a year or more. Treatments including corticosteroid
injections, anti-inflammatory medicine (NSAlD), manipulation and physiotherapy have often conferred only short-term benefit (Croft et al. 1996; van de r Windt et al. 1996; Be rge nudd et at. 1988 ; Vecchio et
al. 1995; Cha rd and Hazleman 1987; Wmters et al. 1999) Variables
that p red i ct ed poor outcome were concomitant neck pain (odds ratio 28), high baseline pain s c ore (odds ratio 20),
a
long duration of
symptoms at presentatlOn (odds ratio 05), and initial referral to p h ysi o th e ra py (odds ratio 0:4, compared to no treaLment or m e dication only) (van der Windt et al. 1996).
Ci-IAI'TER
MUSCULOSKELETAL r'ROlILEM$
Many
patients do not persevere with seeking treatment despite
persistent
symptoms They frequently try health care once or twice
.
When th is does not bring relief they cease attending, but are left
with chronic symptoms th a t they are forced to tolerate. This group with persistent symploms may be as high as 50% of those originally coming forward for treatment
and
We b le y
resolution of
(van der Windt et al. 1996; Chakravarty
1990). This can give the mis ta k en appeara nce of a
problem that in fact persists and is simply tolerated,
and an illusion of treatment efficacy that is il lu so r y There are suggestions in the literalure
lhat shoulder pain recurs, and that many
individuals may have several episodes p rior to the problem becoming chro nic (Winters et al. 1997;
van der Windt
et
Cl1. 1996)
Frozen shoulder is a condition that is frequently said to recover spontaneously
wi thi n six to eighteen months (Rizk and Finals 1982)
Ho w ev e r certain studies show its effect can last for much longer, ,
and that treatment has little effect on outcome. Bulgen
et
al. (1984)
compared intraarticular sLeroids, mobilisations, ice the rapy and no trea tment over a six m on t h period and found that all groups -
irnproved, but lhat lhe re was little l ong- t e r m advantage many regime When these patients ,vere reviewed around four
trealment
years later, aboul half were still found to have persistent aching or restriction of movement, with greater restriction in those patie n ts who had
received mobilisation (Binder
et
al. 1984) Shaffer
et Cll.
(1992) also ["ound about 50% of their study group had mild pain
and/or stiffness when reviewed at about seven years. In a long-term Coll o w-up of patients
with rotator cuff tendonitis who were treated
with NSAlDs, i nj e c tio n or exercise, a yea r and
a half later (Chard
et
nearly 50% were still symptomatic
al. 1988)
Wadsworth (1987) Slates lhat conservative management is successfuI
in 90% of cases of lateral epicondyhtis Although patients frequently im pr ove with ultrasound or injection,
when reviewed up to five years
laler about 50% of study groups had pain and functional limitations, al t h o u gh few had so u gh t further treatment fo r the problem (Binder and Ha z le m a n 1983; Clarke and Woodland 1975; Hamilton 1986) '
Tennis elbow' clearly has a high rate of relapse and failure to resolve.
The evidence would thus suggest that the experience of persistent musculoskeletal common
problems, which are res istant to treatment, is very
in the general population The lack of long-term follow-up
and the withdrawal of patients from therapy generaLe the illusion of
ONE
115
161 CHAPTER. ONE
THE
HUMAN
EXTR.EI\;\ITIES: MECHANICAL DI AGNOSIS & THEI1.APY
therapeutic efficacy for many interventions. However, for a vast number of patients, the reality is persistent pain and functional limitations.
Systematic reviews of commonly used treatments Systematic reviews of randomised controlled trials, because they pool the results of several studies, are said to be the optimal way to Judge the efficacy of different treatments (Gray 1997) Systematic reviews frequently rate the trials poorly against the criteria by which they judge the methods used in that trial. They also generally find little firm evidence to support c ommonly used interventions for musculoskeletal problems. "The evidence in favour of the efficacy of steroid injections for shoulder disorders is scarce" (van der HeiJden et aL 1996) "There is little evidence to support or refute lhe efficacy of common interventions for shoulder pain" (Green et al. 1998). This review looked at treatment with anti-innammatory (NSATD) tablets, injections and physiotherapy "There is evidence that ultrasound therapy is ineffective in the treatment of soft tissue shoulder disorders..
Evidence for the effectivel1ess of
other methods of physiotherapy is inconcl.lsive" (van der Heijden eL al. 1997) One group reviewed the use of ultrasound, ionisation, oral NSAlD and steroid injections for lateral epicondylitis and "concluded that there was insuffiCient
SCientifiC
evidence to support any of the current
methods of treatment" (Labelle et at. 1992)
A systematic overview of steroid injections lor lateral epicondylitis found a favourable treatment effect at six weeks, but a lack of long term effect after this (Assendelft et aL 1996). "There seems to be little evidence to support the use of ultrasound therapy in the treatmenL of muswlosheletal disorders" (van der Windt et al. 1999) Systematic reviews and meta-analyses have an inherent problem in that they are only as good as the clinical trials they draw their conclusions from. In the attempt to make a general conclusion, trials
with different procedures, measuring tools and outcomes are lumped together with the assumption that greater generalisable 'truths' can be gained from disparate studies. While the quality of methods is
C H A PTE R ON E
MUSClJl.OSKEl.ETAl. PROlILEMS
strictly adhered to, the quality or exact type of intervention may be obscured Although it is certainly pertinent to question the validity or their conclusions, in all instances the message from these rev iews cannot be ignored. They testify to the inconclusive treatment effect of many commonly used interventions These findings in fact acc ord with what is clear from the
epidemiological literature outlined earlier - that many people have persistent or recurrent musculoskeletal problems that are either resistant to treatment or respond only temporarily. It suggests we should begin to reformulate the problem - not what can we do for our patients, but what can our patients do for themselves.
This is
bound to involve exercise therapy
The only intervention that consistently appears beneficial across a wide range of spinal and non-sp inal musculoskeletal problems is exercise.
"One ((In draw a number o j conclusions, however. First, and importantly, exercise appears to be the best modality. St rengt hen i n g muscles protects the joint. Secondly, most oj the machines that plug into the wall a re acting as flashy placebos" (Clarke 1999).
"there is littl e evidence that any oj the therapies under review cause improvements in symptoms oj c h ronic museulosheletal pain or in quality oj liJe t hat outlast the therapy . ". Only two trials reported positive long-lerm treatment effects. "The treatment groups in both oj these trials re c e ived exercise" (Feine and Lund 1997).
Mter reviewing a wide range of interventions Feine found
.
.
common with other areas oj musculosk eletal rehabilitation, the evidence strongly supports exercise (except possibly in the rare case oj true radicular bach pain) and a c ogn i t ive beha vio u r al appro ach to pain management" (Haigh and Clarke 1999) "In
"Exercise
re
d u c e s pain and improves Jun cti on in patients wi t h
osteoarthritis oj the knee"
(Puett and Griffin 1994)
The available evidence does not support the treatment efficacy of many commonly used interventions for musculoskeletal problems. The one exception to this general rule is the widespread finding that exercise is beneficial across a variety of disorders. Rather than looking to short-term curative treatment solutions meted out by clinicians, we should be offering education and self-management strategies lor
patients to use which will be of long-term benefit.
117
181 CHArTER ONE
THE HUMAN EXTREMITIES: MECHANICAL D1AGN05IS
&
TJ-IERArY
The problem of diagnosis Musculoskeletal problems about the shoulder are clearly common. This affects about 10% of the population at some point, and 59;', of all consultations in general practice relate to pain about the shoulder (van der Heijden et al. 1996, 1997) What sort of problems are these) The commonly given diagnoses by GPs and physiotherapists in the
UK and Holland are as follows Table 1.3
Diagnosis given by clinicians for shoulder conditions
Dia,gnosis ROlator
cuff injuries
Windt
CrofL
Liesdeh 47%
30%
Capsulitis
22%
Acute bursltis
17%
7%
Chronic bursitis
13%
9%
4%
6%
Acromio-clavicular Joint
Chard
40%
17'Y"
18%
These findings suggest considerable variety in what different clin ician s think they are seeing. These kinds of diagnoses are commonly made in the clinic and are based on the ideas and criteria proposed by
James Cyriax (1982), the founding father of onhopaedic medicine. The concepts, although widely accepted, have rarely been s u b j ect e d to detailed scrutiny Two key issues have not been fully investigated -
the validity and reliability of the tests used to make these diagnoses.
Validity relates to the ability to measure what is intended Reliability is the extent to which a measure is reproducible, or gives lhe same results, in different situations (Streiner and Nonnan 1996). If different clinicians come to different conclusions using the same test, clearly that test is of little value in deciding treatment strategies Reliability of a test between cl i ni ci a n s is a first step in evaluatmg the usefulness of diagnostic pathways to treatment. Work done in this area is contradictory In nearly 400 cases of shoulder pain, 141 were examined twice by their physician; in nearly half of these the initial diagnosis was changed (van der Windt et 01. 1996) In other words, on subsequent analysis the GPs altered their diagnosis.
Of these patients, 120 were referred to a physiotherapist who also diagnosed the patient according to tne same diagnostic critena. Cohen's Kappa is the statistical test used to evaluate agreement between clinicians as it takes lnto account the proportion of agreement that may occur by chance (Srreiner and Norrnan 1996) The overall strength of agreement between the GPs and the physiolherapists was
C H A PT E R O N E
M U S C U L O S K E L E TAl P RO B L E M S
Kappa 0 . 3 1 (Li e sdek e t al. 1 997) This re n ects only a ' fa i r' concordance betwee n t he c l in i c i a n s a n d s e r i o usly q u e s t i o ns the re h a b i li ty o f these d i agnost i c c r i t e r i a i f d i ffe r e n t exa miners can rea c h such d i ffere n t c o n c l u si o n s . H o w e v e r , e x p e ri e n ce d t h e r a p i s t s u sing t h e C y ri a x
eval u a t i o n p ro c e d u re we re highl y rel iable ( K a p p a = 0 87) i n se lec tin g d iagnostic cat ego ries i n 1 9 o f 2 1 patients wi th shou l d e r pam ( P e ll e chi a et
al . 1996)
P o o r leve ls o f a g ree m e n t have been fo u n d in tests used in the c l inical assess m e n t o f kn e e pro b lems . Alt hough 'w i th i n observ e r a gree m e n t' o f vari ous tests used to evaluate osteoanhri tls i s moderate to exce llent ,
'betwe e n o b s e rver agre e m e n t ' is p o o r to m o d e ra t e U ones et al . 19 9 2 : C us h na g ha n et al
1 990) F o r b o th w ithin and between observer
var i a t i o n , h is t o ry - ta k i ng is much more re li ab l y assesse d than physi cal signs , and t h e agreement between observers a b o u t physi c a l signs o nly was p o o r
U o ne s
et
a l . 1 992 )
Certai n e l e ments of the CYliax
examina t i on of the k nee h ave also been shown to have only poor t o
fai r re l i a b i l i t y These were the j u d gements t h e rapists m a d e about end fee l and the s e q u e n c e 0 1- p ain and resistance w i th m o v e ment (Hay e s et
a l . 1 994) . F o u r com monly u s e d tests t o e v a l u ate p a te U o femoral
malalignme nt ha ve also been s h o wn to have only p o o r to fair r e l iability ( Ka p p a = 0 1 t o 0 36) (Fitzgera ld and M c C l u re 1 995 )
1 t is c le a r l y w ise to be cau tious a b o u t t h e re lia b il i t y and thus the value 01' c o m mon l y used t ests . A l t h o u gh they o ften have a reasonab ly good r e co rd o f p ro d u c i n g the same resul ts when re p e a te d b y th e
same c l i n i c ia n , t h e y ge n e r a lly have a p o o r record o f p ro d u cing the same res u l ts "vh e n used by di fferent clinicians . If the tests are suspect , the n t he d ia g n oses reached by these tests m a y also be sus p e c t I n t h i s ins t a nce s hou l d we aga i n b e reform ulating t h e question? S h o u l d we some t i m e s fa v o u r ge n e ra l diagnostic p a t t e rns , wh i c h suggest trea t men t d i re c t i o ns , rather than s p e c i fi c d iagnostic criteria t hat a re u nr e l i a b l e ? S h o u l d t h e s e g e n e r a l d i a g n o s e s b e b a s e d u p o n sym p L O m a t i c histo ry-taki n g , which o ften appears t o b e m o re re l iable
t han p h y s i ca l signs? The tests t h a t a re commonly used
[0 m a k e d i a g n o s e s i n
muscu l os kel e L a l d isorde rs a re n ei t h e r proven t o b e r ep ro d U C i bl e n o r to measure wha t i s intended T h e diagnoses the mselves m a y t h e re fore b e s u s p e c t a n d rep r esen t an u n t ru s tworthy base u p o n which to e s tablish t re a tme n t p ro tocols .
119
I
20 C H A I'TE R
ON E
THE
H U M A N E XTfU M I T I E S :
M E C H A N I CA L
DIAGNOS I S
& TIH RA I' Y
Conclusions This chapter has presented t he contex tual bac kgro u n d of m usculo skeletal proble ms. Certai n facts stand ou t m u sc u loskele tal pro b l ems are one of t he most com mon conditions that affect people in the community su ch condi tions a re prevalent in all body regions, but especially in
the large j oi n ts of the shoulder, knee, a n kl e and hip
these problems are very often persistent and c h ron ic, even in those who have received trea t ment suc h patien ts frequently seek health ca re serv ices and m a ke up a signi ficant proportion of those who attend p ri m ary ca re physic ians and physiothera pists t rea tment, al though somet imes con ferring sh o rt-te r m relie f, freq u ently does not resu l t in a cure of the pro blem •
the only intervention tha t consisten t l y does a p pear to be able to confer benefi t is a se l f-management a pproac h using exerc ise and behavioural modifica tion disillusionmen t w i th p rofessional h elp an d opting out of [u rLhe r t rea tment is common commonly used treatmen t options
in
m usculoskeletal con di tions
have a very inconclusive record o f efficacy in contro lled trials and systematic reviews the valid i t y a nd reliability of a ccep ted d i agnostic categories
a re
uncerta in, a n d the extent of non -spec i fic musc ul oskeleta l problems in the pe riphery is un known . These facts suggest a fa ilure on the part of the med ical mode l , 'vv h i ch purports to d iagnose , trea t and cure . The approach out l ined in this book proposes a di fferen t model , based upon non-spe ci fic syn drome cl assi fication a nd the overwhelming logic o f endorSing the key role of sel f-managemen t stra tegies in m u sculoskeletal med icine. H a condition is very common , persistent a nd resistant to easy remecly, it is ti me that the patien t is fully empowered to dea l with these prob lems in an opti mal and realistic fashion. As clinic i ans we shou l d be offering this e mpowermen t to our pat ients
CHArTER Two
2: Soft Tissue Properties
Introduction Tl1e previous chapter has shown that pain in the perip he ral joints
and soft tissues occurs frequently in the general popul a tJ on and is a cornmon cause for see k i ng health care services. The concern of this text is the prob l e ms that affect the soft tissues of the limbs. It is thus uselul to revi e w some of the pro pe rties of these tissues including
how injury oc c u rs , the effect of inj ury, the healing process, and what can inhibit the h e aling process. As it is vital to recoll e c t that tissues are part 01- a whole being, some of the impact of behaviour on these
pro pe rties will also be cons ide re d. How these tissues maintain their function through use and a t rophy through disuse are also esse ntial
elements of appropriate management Recognition must also be made of the role oj cumulative trauma and insidious d egenerati o n in the onse t of some muscul oskeleta l problems. The clinical implications of these factors will be discussed.
Tissue injury Tissue damage may result from a discrete traum atic episo de with a sudden onset of pain, or it may arise insidi ously due to cu mu lative trauma when overuse or
d ege neration
is present Altho ug h there has
been no overt incident in these cases, repetitiv e loads can be suffici e n t
to cause mi c ro trauma or degenerative c h anges to the tissues -
overwhelm reparative
,
processes and evoke an infl ammato ry response.
Shoulder capsulitis, te n osy n ov itis and lateral epicondylitis all c omme nce with an a c ut e inflammatory period, and usually an insidious onset. Thus injury is the result of intrinsic or extrinsic factors, either a lone
or
in
c o mbinat i o n
with chronic conditions
re presentin g an interaction between the two categories
al 1997)
Wha tever
(K a nn us et
the c a use if tissue da m a ge has occurred the ,
inflammatory p ro c ess will be triggered (Levine and Taiwo 1994)
Recovery following trauma Following tissue inJ ury the proc ess that theoretically leads to recovery
is divided into three ov e r l a pp i ng phases
-
inflammation, repair and
re m odelling (Evans 1980; Hardy 1989; Enwemeka 1989; B arlo w and
121
1
22 CHAPTER Two
THE HUMAN EXTREMITIES: MECHANICAL DIAGNOSIS & THERAPY
Willoughby 1992; Norris 1993). "No inflammation /
no
repair is
a
valid dictum" (Camco et al 1984) In fact, each part of lhis process is essential to the st ructure of the final result Connective tissue and muscle do not regenerate if damaged but are replaced by inferior ,
fibrous scar tissue (Evans 1980; Hardy 1989). To produce optimal repair tissue, all phases of this process need to be compleLed at the appropriate time.
Inflammation In response to tissue d amage a host of inflammatory cells wilh
specialist functions are released and attracted to the damaged area. There is increa sed local blood supply, leaking of plasma proteins and leukocytes from the blood vessels and accumulation of white ,
cells at the site of the inj u ry (Enwemeka 1989; Evans 1980) These cells wlll be involved in the clearance of dead and dying cells and any foreign matter prior to the re-growth of new vascular channels and nerves into the damaged area. The cardinal signs of inflammation,
heat, redness, pain, swell i ng and lack of function may be displayed (Evans 1980) and are a result of the inflammatory exudate. The swelling, heat and redness are products of the vascular aCLivity; the pain results from the presence of noxious inflammatory chemicals and heightened mechanical sensitivity Another sign 0 f in [lammation is increased tissue sensitivi.ty to ordinary me c h anical stimuli; this will be discussed in the next chapter In optimum conditions the inflammatory stage lasts less than five
days, with a gradual reduction of inflammatory cel ls lhereafter and
none present at the end of the third week (Enwemeka 1989) In this period a mesh of fibrin forms from the protein fibrinogen in the inflammatory exudate and seals the injury During this time the application of ice, co mp ression
,
elevatIOn and gentle muscle
movements are indicated to reduce the inflammatory exudate (Evans
1980) The greater the amount of exudate, the more hbrin will be formed and the more inextensible will be the rep a ir Ice, if a pp lied in the first few days follOWing injury, can reduce pain and oedema lee is of little value after the fifth day as the inflammatory cells are replaced by fibroblasts. These soon begin to lay down fibrils of collagen
Tissue repair The fibroplastiC or repair stage thus commences as the acute infla mmator y stage subsides and lasts about three weeks (Enwemeka 1989). It is during lhis phase that the collagen and
CHAPTER
SOFT TISSUE PROPERTIES
glycosaminoglycans that will replace the dead and damaged tissue are laic! dow n There is cel lula r proliCeration, which results in a rapid .
increase in the amount of collagen, and damage d nerve endings and capillaries 'sprout' and infiltrate the area
(Cousins 1994).
The cellular
activity is stimulated by the physical stresses to the tissue. With inactivity, c ollagen turnover occurs and new collagen is made, but it 1S not oriented according to stress lines At the end of this phase
hbrous repair should be established and collagen mass is maximal, but the tensile strength of the new tissue is only 15% of normal CHardy 1989) To encourage good quali ty repair with collagen fibres orien ted according to stress lines, gentl e natural tension should be applied to recen t injuries, commen c ing at about the fifth day (Evans 1980) Gentle te nsion applied early in the heal ing process will promote greater tensile strength in the long term. From the first w e ek a progressive increase in movement should be encouraged so that full range is possible by the third or fourth week It
is within this p eriod that appropriate education and movement proVides the op timal climate for uncomplicated re p ai r An experimental animal model showed that .
the application Ol stress during this repair phase was able [0 change the length of scar tissue, and thus remodel it according to function
The
same stresses applied to scar tissue that was three months old
had little effect on its length (Arem an d Madden 1976) It should be nOled, however, that at this stage if an over-enthusiastic approach to treatment is adopted, the repair process can be delayed or disrupted and the presence of innam matory chemical irritants
and exu d ate will be p rolonged or re-stimulated. During this early stage of he a ling movements should be just into stiffness and pain ,
and entirely under the patien t s control. Any discomfort provoked '
by the movement should abate as soon as the movement is released. If lasting pain is p rovoked it is likely that re-inJury has occurred, the innammatory phase has been re tri ggered and resolution of the -
problem will be funher delayed
.
Remodelling Wound repair is only optimal if remodelling of the scar tissue occurs. This involves increasing s trength and fl exibility of the s car tissue through progreSSively increased normal usage and specific loading Remodelling is the process of turnmg weak, 1mmature and disorganised scar tissue into a functional structure able to perform
Two
123
241 CHAPTER Tvvo
THE
HUMAN I XTREMITIES: MECHANICAL DIAGNOSIS & THERAI'V
normal tasks. The repair is unlikely to achieve the s t re ngth of t he original tissue, but progre ssive loading and mechanical sti m ulation enhances the tensile strength and improves the quality of the re p air
.
This occurs over several months after the original in] ury. Tensi Ie strength is increased by stabilisation of the fibres through cross linking, alignment of the fibres along the lines of stress and synthesis of type I collagen (Barlow and Willoughby 1992; Witte
and Ba rb ul 1997) Several factors can promote a less than optimal repair The granulation tissue, which repaired the damage, can now act as glue to prevent movement between tissue interfaces. During the period when collagen turnover is accelerated, there is also increased molecular cross-linkage - these processes may produce adhesion fo rm ati o n and impair collagen gliding (Hunter 1994; Donatelli and Owens-Bu rkhart 1981) Newly synthesised collagen will tend to con tract after three weeks; this naturally occurnng s hrinkage is said to continue for at least six
m ont hs if nOl fo rever (Evans 1980) Thus recently formed scar tissue ,
will commence shortening unless it is repeatedly stretched The
stretching process should be commenced in the early stages following" injury and continued until well after full recovery so no soft tissue shortening is likely to develop. Low-load regular application of stress
will also help to increase the tensile str ength of the repair tissue (Hardy
1989) Failure to perform the appropriate tissue loading will leave the repair process complete, but the remodelling stage incomplete; the indiVIdual may still be b othered by pain and limited [unction, and the tissue will remain weak and prone to re-injury The ner v e s
,
which infiltrated t he tissue d u r ing repair, can now be sources of pain each time the scar is stretched or loaded. This is a common cause of persistent symptoms in many patients. The regular application of intermittent stress or loa din g to bone and normal soft t issu e enhances structural integrity through the process of remodelling During the healing process loading for prolonged periods must be avoided as this may disrupt the repair process. Prolonged stress damages; intermittent stress strengthens Thus the p r oper rehabilitation of tissue damage involves progressive, incremental loading and act i v i ty in order to r es tor e the SLructure to full function and to restore the pacient's confidence to use it This is t h e essential ma nageme nt strategy during the repair and re m o d elli n g stages
CHAPTER
SOFT TISSUE PROI'ERTIES
In summary, no inlury ca n be made to heal faster than its natural rale; whenever the r e has been tis sue damage the processes of
i n fl a m m a ti on repa ir and remodelling h a ve to occur to allow full ,
resto ra ti o n of n o rm a l function. "Failure oj any oj these processes may result in inadequate or ineffectLwl repair leading to either chronic pathological changes in the tissLle or to repeated structural fail u re
(Barlow a n d Willoughby 1992)
"
T h e se processes are essentially the
same in te n d on s, muscles, lig a m e n ts and a ll soft tissues; however,
i n trins ic ["actors may be te n do n
m o re likely to im p ai r the
recovery process in
injuries, especially if the onset is through overuse rather than
trauma (8m"low and Willoughby
1992) Early progressiv e active
rehabilitation is essential to optimise repair and function. No passive
modality used within physiotherapy has yet been sho \VTI Lo reduce the t i m e for the completion of natural healing. We can avo i d delay to
the heali ng process and ensure t h at the climate for re p air is fav ourable (Evans 1980) Strenuous mechanical therapy applied when the pain
from the injury is essentially c h e m i c al will delay reco v er y The integrity of the repair must be established before more v igorous procedures are applied. H ow e v e r of equal importance is the use of a ,
"progressive,
c
o n tr o l le d programme of load i ng the tissues at the
a pprop r ia te time d ur i n g the rep ai r process in ord er to promoLe a fully func t io n a l structure which the p a tien t is confident to use. Those [actors that may I"esrricr a return to normal funcnon are listed in
more detaillatel" Table 2.1
Matching the stage
Injury &:
}1
InOammation
Rep,
& ",,",,"
of
condition to
the
Protect from
management
further damage.
Prevent excessive inOammatory exudate.
Reduce
swelling
�
Gentle nalural tension and loading. Progressive reLUrn to normal loads ancl tension.
Remoclelling
Prevent
contractu res.
Normalloacling anclrension to increase strength
and
flexibiltty
Two
125
261 CHMIIR Two
THE HUMAN
EXTREMITIES: MECHANICAL DIAGNOSIS & THERMY
Failure to remodel repair tissue Following tissue damage an important factor in the physiology 01repair is the phenomenon of contracture of connective tissues. A characteristic of collagen repair is that it will contract over time. Recently formed scar tissue will always shorten unless it is repealedly stretched, this contracture occurring from the third week to the sixth
month after the beginning ol the inflammation stage Contracture of old scar tissue may in fact occur lor years after the problem originated ( Evans 1980; Hunter 1994) Cross-linkage between newly synthesised collagen fibres at the time of repair can prevent full movemel1l. Nerve endings infiltrate this area during the repair process and can makc the scar tissue a sensitised nodule of abnormal tissue (Cousins 1994)
Time course of cellular activity following tissue injury
Figure 2,1 30
____
cells
dying
� I
??V> U U
\
11
\
r I
V
I-r-:-.....
- - - lurl
I. �'V \ J J I
Ii' / 3
r-
:\ lL"
., \ \
\
::. 9
'\tII
l3
t-r
t-f::f::
r l5
17
19
2.1
- - - . NelHmphd<;
'\ 1\
-- Flhrohlast :1C1I\'i\�
t-i13
2S
# or Days
In some patients contracture resulting from previous injury may now prevent the performance of full range ol motion These patients will have been umvilling to stretch the recent injury, percei\ring the 'stretch' pain as d enoting further d amage , and they will not have received appropriate rehabilitation advice at the time of the injury They will present later with restricted range of movement and pain pl-ovoked by stressing the scar tissue. The tissue w1l1 be come progressively more sensitised and deconditioned for normal function with lack of use Tn such cases the remodelling of collagen by applying
a
long-term
structured exercise programme will be necessary By applying regular stress sufficient to provi de tension without damage, collagen undergoes chemical and structural changes that allow elongation and strengthening of the affected tissue. Because tissue turnover is slow, it must be recognised that it
may be a slow process If the contracture
CHAPTER.
SOFT TISSUE PROI'ERTI ES
has been present for some time, the remodelling programme will have to be followed for several months. Evans (1980) reports that some patients may have to exercise lor the remaining years of their life Stretching of old injuries should be routinely practised, especially prior to participation in sporting activities (Hunter 1994) The animal experiment Ol Arem and Madden (1976) showed that 'old' scar tissue might be unresponsive to a remodelling programme Well established COlllraclures, especially where the original healing process has been interrupted by repeated re-inJury causing the production of more
inflammatory exudate, may be resistant to improvement. Degenerated tissue in which healing is suspended Certain chronic conditions in which symptoms remain relatively stable over time appear to get 'stuck' in the repair process. This occurs in degenerated structures in which symptoms have arisen insidiously, as
in such tissues the repair process is less effective (Buckwalter et
al.
1993) Degenerative tendonopathy is thought to be clue to hypoxia and micro-trauma and arises silently, so that complete ruptures Ol Achilles' tendons have occurred without prior symptoms (Leadbetter
1992; Kannus and Jozsa 1991) There is fibre disorientation, hypocellularity, scaLLered vascular ingrowth and occasional necrosis or calcification (Leadbetter 1992) Such degeneratlVe changes in tendons are found in about a third of the general population over 35 (Kannus et al. 1997) [n persistent tendon problems histological investigations do not reveal any inflammatory cells (Verhaar et a!.
1993: Nirschl 1992: Chard et al 1994: Kannus et al. 1997).
In these
instances the orderly phases of the healing process are aborted or absent (Leadbetter 1992). This failure to repair may result from a combination of slow or failed healing, avascularity, degenerated tissue and lack of appropriate stresses (Fukuda et al. 1994: Chard et al.
1994: Leadbetter 1992) Failure to remodel adequately leads to imperfect repair. Symptoms will persist in this state. To stimulate the remodelling process in this degenerated tissue a different approach may be needed
In such
instances vigorous stimulation of the tissue, so that the healing process is re-triggered, is often beneficial. There \vill be a temporary provocation of pain and aggravation of symptoms Once this has been achieved the aggravating stimulus should be stopped, and progressive loading, as in the sub-acute model, should be introduced.
TI-vo
1 27
28 1 CHAPTER Two
THE HUMAN EXTREMITiES: MECHANICAL DIAGNOSIS & THERMY
The effects of stress deprivation and exercise on connective tissue Both following injury and in normal health the opti m a l function o[ musculoskeletal structures is maintained by activiLy The detrimental effects of immobilisation on connecLive tissues are well known CAkeson et al. 1987, 1989, 1 991 ; Frank et al. 1984). Repeated experiments, mostly with animals, have documenLed that in the absence of normal stresses these tissues weaken, atrophy, develop contractures and adhesions, and become generally unfit lor normal function (Gelberman et al. 1 982 ; Amiel et al. 1982; Houlbrooke et al. 1990; Videman 1987; Donatelli and Owens-Burkhart 198L McDonough 1981; Woo et al. 1987) It is especially important to note that following injury connective tissues consistentl y respond better to early motion than to immobilisation (Gelberman et a/1981, 1982; Houlbrooke et al. 1990; Arem and Madden 1976; Jarvinen
and Lehto 1993). Various authors (Akeson et al. 1987; Bland 1993: Videman 1987) have listed the negative effects of immobilisation on connective tissues. They include: increased random deposition of collagen fibrils increased collagen cross-links pannus form a t ion over ca r t i lage surfaces ulceration and loss of thickness of c a rt ilage dramatic loss of tensile sLrength formation of adhesions and contractures in a nd between the synovi.al membrane, capsu l e and other tissues •
degradation of the ligament-bone interface generalised osteoporosis of c ancello u s and cortical bone
In summary, the efl-ects of stress deprivation are Lhus to weaken and atrophy ligament, tendon and bone, as well as muscle: to degrade surfaces and tissue interfaces: and to cause disorganised tissue to bond randomly together. Bland (1993) makes clear the implications of these changes lor the patient "The clinical issue is that the damage occurs very rapidly and the repair is extremely slow and less predictable, a heavy price to pay for immobilisatiol1- total, partial or even relative immobilisation" Cp. 100)
SOFT TISSUE rl(OT'ERTIES
CHArTEI( Two
The converse side of this picture is the beneficial effect which early
motion after inJu ry and exercise has on strengthening and norma lisin g COl1l1ective tissue fUl1ction (Akeson et al. 1989, 1991; Salter 1989; Frank et al. 1984; Woo et al 1987) Experimental and c l in ica l work attests to the value of early mollon il1 strengthe l1i l1g ten dons a n d l i gam ents, restoring full range of movement, reali gni ng collagen fibrils along lines of stress, p re v enti ng
adhesion formation,
and p reserving
anicularcanilage (Frank et al. 1984; Gelberman et al. 1981,1982; Evans 1989; Houlbrooke 1990; Woo et al. 1987) As with these other
tissues, muscles atrophy in response to disuse, but h y p e rtroph y wh en s ubje c te d to i n crease d use (Pitman and Peterson 1989), and regain
function more e ffec l i ve l y when mobilised from a few days a fte r i nj u ry Bone has the ability to respo n d to
Oarvinen and
Lehto 1993)
increased stress
by remodelling and
alteri ng its structure to m eet the
ph ysical demands placed on it ( N ordi n and Frankel 1989a!. This phenomenon, in w hich bone will alter its dens ity an d s hape according to the mechanical stresses put upon it, is known as Wolff's Law (Bland 1993) The application of Wolff's Law has been c riticised for being too limited, and many
au thoriti es see
It rightly ap plied to
all connective tissue , not only bone (Bland 199 3 ; Akeson 1989; Akeson el. al. 1991)
It re f l e c t s the truism th a t anatom ical tissues and
st r uc ture s wi 11 lend to re flec t the functional stresses demanded of them. Progressively i nc r e ased loads will str engthe n tissues and enhance function; stress deprivation will
cause atrophy and
dys fu n c t ion . Even in the instance of a comp romise d osteoarthritic Joint, when
destructive loa d i n g and stress de pri v at ion may co-exist in different parts of th e same joint, the possible value of exercise should not be forgot ten (Akeson 1989) Animal experiments have shown that with continuous passive motion, healing and regene r a tion of cartilage may occur (Salter et al. 1980)
Immobilisecl joints show signs of
osteoarthritic lesions, w hile with normal loading the j o i n t surfaces returned to normal; however, excessive exercise at this point
agg rav ate d the degenerative sequence (Bland 1993), Bland p r o poses that "well go v e rn ed and practised exercise and mechanical stimulation oj the involved tissue may aid in ar rest or reversal oj the process" (p. 107) finally, besides the phYSiological benefits which exercise br i ngs to Joints, con n e c t i ve tissues and muscles, as well as the cardiovascular
129
30 I CHAPTER Two
THE HUMAN EXTfUMITIES: MECHANICAL DIAGNOSIS & THERAPY
system, it is importanlto remember the ps y ch osocial implications of inactivity versus activity "The result of a decrease in physical activity combined with a reluctance to maintain a level offitness with increasi ng
chronological age and a general failure to apprec iate the dependence on p hys i ca l stresses for continued fu ncti on a l i ntegrity wi II lead to the degradation of all connective tissue; in a word, retirement - both
intellectttal and physical" Bland (1993 100) This applies even more in the presence of a pain fu l condition. It has been pro p ose d thai fear of movement and re-injury
l e a ds
[0 av o i d ance ol ac t i v i ty and
consequent disability, disuse and depression. A co nlinuing vi ci ous cycle is created in w hi ch the p ai n ful experience and reduced functi on persist. Those able to confront the i r pain and follow
a
prog ressive
return to normal activity are more Itkely to make a full recovery
(Vlaeye n 1998). Numerous physiological improvements have been attributed to exercise ; these relate not only to maintenance of normal function, but also to their favourable effects on th e natural history of various
(fentem 1992) F unctions and be en h anced by re g ular exercise
diseases and degenerative conditions structures that have been shown Lo a re t h e fo11owi ng •
cardiovascular [unction skeletal muscle tendons and connective tissue the skeleton
•
j oi nts m etab olic fun ction psycho logical func t i on
.
Factors restricting a normal return to function Injuries cannot be
m ade
to heal faster than then natural speed
.
Without completion of any of the three phases the scar tissue will n ot be ade quate for normal function. F ai l ure in any phase of the repair p rocess
may
result in ineffectual healing lea ding to chronic
degenerat i ve ch anges repeated structural fa il ure or less than optimal ,
tissue (Evans 1980;
C arr i co
,
et al. 1984; Barlow anel Willoughby
1992) If the tissue is still stiff and painful long after the expected period of heal i ng , the i nd i vid ual may be anx io u s and lose confidence
50FT TISSUE PROI'ERTIES
CHArTER
about using the struClur e properly We must make sure that no cont r a ry inr\uences mtrude and that the best pos si ble conditions are encouraged Various probl e ms may prevent or IOhibit healing and
return to lull function. Some of t hese factors are more amenable to
inlluence than others. Age or pre-existing degeneration is an important prognostic v a ri ab le to be aware of, but difficult to affect
S om e 01 the se factors relate to the tissue env iron ment some to the ,
individual's response LO injury; both elements may contr i bute to
retarded healing. [n the l ong term return to full function reflects -
behavioural responses as much as the cellular he a lin g process. Inappropriate action based on misconceptions, poor advice or
avoidance can be as deleterious to full recovery as the wrong chemical environment.
Following
are
some [acLors that may inhibit the healing process a n d
return to full fu ncti on (Evans 1980; Carrico et (/1. 1984; B arlo w and
vVilloughby 1992; B u c kwalter et al. 1993; Linton 1996)
poor blood supply or ischaemia - es p eC ia l ly relevam in tendon
injuries where intrinsic vascularity may be poor and where t h ere is very high tissue pressure or absolute immobilisation
lack of initial protection and r edu ction of swel ling (first few days) lack of early mobilisation - gentle n a t u ra l tension encourages good quality repair ( sta rt i ng within the first week post-injury) continued inflammation; anything that prolongs or re-triggers
this phase will cause poor healing - for in stan ce infection,
a
haematoma, or excessi ve premature vigour systemic or local steroid medication - decreases the tensile stre n gt h o[ wounds, slows the rate of wound c los ure and
vascularisation nutrition - malnourisnment inhibits the body's re s po n se to
injury diabetes
-
mechanical problems and metab o lic defects i mpa ir
wou nd he a ling over-abundant depO Si t ion of coll ag en - keloid scar formation levels of phy s ic al activity; the level must be appropriate for the stage as ouLlined above 1f too much vigour is employed too
early or if duri n g remodelling in adequa te stresses are appl ied
Two
1 31
32 1 C H A PT E R T w o
T H E H U MA N E XT R E M I T I E S : M E C H A N I C A L D I A G N O S I S & T H E R Ar Y
t o the re p a i r tissu e , t h e end p ro d u c t can b e the same - poor wou n d healing and i m p a i red fun c t i o n a ge - t h i s c a u s e s a d e c l i n e i n fu n c t i o n , a n i n c r e a s e i n s u sc e p t ibility to inj u ry a n d d i sease , a n d a d e c rease i n t h e a b i l i t y t o re cover fro m inj u ry a n d d isease . T h i s is n o t u n i fo rm , however, a nd occu rs a t extremely variable rates be tween i ndivid u a l s i n a p p ro p r i a t e b e h a v i o u r s i n d e a l i n g W i L h p a i n a n d i ts consequ e nc e s Resp o nses which have b e e n i m p l i c a t e d i n t h e deve lopmen t o f chro nic p a i n a re b e l te f t ha t a c t i v i t y c a u s e s p a i n o r injury l e a d ing t o fea r-a void ance beha v i o u r, use o r pass l v e c oping s t ra tegie s , anxiety, l o w se lf- e fficacy be lie fs , exte r n a l hea l t h locus o f con trol b eliefs , d e p reSS i o n , catastro p h i sing a bo u t the s i t u a tion , l a ck of p ro p e r i n formation inappro p riate behaviours on t h e p a rt of h e a l th care p ro fess i o n a l s - encou raging p a tients to a d o p t s i c k - ro l es , o b t a i n s i c k l e a v e , a n d o ffe ring passive , cl i n ician - l e d t re a t rn e 11l s t rategies w h i c h help mainta i n l o w s e l f- e fficacy a n d e x t e rna l h e a l t h l o c u s o f c o n t r o l b el i e fs i n the patient
Cumulat ive postural stresses on muscul os keletal tissue S o fa r the be n e fi c i a l effe c t of a pp ro p ria te t i ss u e l o a d i n g has b e e n a d d resse d . However, the re a re instances when re p e a t e d o r s u s tained m e c hanical s t ress o n tissues c a n be d a magi n g . M a n y c o n cl i t i o ns stan in S i d i o u s ly and so the role o f d a i l y re crea tio n a l a n d occu p a t i o n a l stresses o n m u s c u loske letal s t ru c t ur e s m u s t be recogn ised . D e ge n e r a tive p ro cesses o r rep etitive m i c ro - t r a u m a , which ove rwh e l m s the tissue 's re para tive p ro cess , may produce sym p toms ( K a n n u s e t at
1 9 9 7) Te nclons i n pa rticu lar a re p ro n e t o d e ve l oping c h ro n ic o v e r use i nJ u ries
C ontract ile t issue l oadin g A l though contractile e l e m e n ts a re c o m m o n l y i nj ur e d tra u mat ically d u ring spo rting a c t lv i ties , m us c u l a r inj u ri e s a l so fre q u e n tl y arise i n a n i nsi d i o u s ma n n e r fro m excessive i n te r n a l fo rces ge n e ra t e d b y o c c u p a t i o n a l o r d o me s t i c tasks . D ur i n g s u c h a c t i v i t i e s d i ffe re n t m u scles m a y be c o ntra c ti n g to p ro v i d e a stabili sing or a move m e n t ge nerating ro l e . In o th e r words , t h e c o n trac t i o n m a y b e iso m e t ric ,
S O F T T I S S U E P R O P E RT I E S
C H A PT E R T w o
du ri ng w h i c h a J oi n t position i s main tained , or concentric or eccentric ,
d ur i n g w h i c h the J oi n t is moved. Those m uscles pe r forming isometric \vork are u n d e r rela t i vely c onsta n t l oa ding an d can su ffer from i schaemia or m i c ro- trauma of fibres even though they may not be req u i red (0 c a use any m ovement. Other musc les i nvolved in the same acti v i t y may be requi r e d to relax and c on t r a c t a l terna te ly in order t o c reate movemen t. In performing t h e same task, some muscles wil l be requ ire d (0 be a c t i ve b oth eccentrically a n d con cent rical l y. I t is
there fo re the case t h a t i n many activities , non-moving contractile stru c t u res can be stat ical ly load e d to the point of fai l u re as readil y as con t ra c t i l e stru ctu res involved i n the actual m ovement . In
t he e x tre m i t ies p ostural pain m a y arise from con t ractile struc tu res
as a c onse q u e nce of p rol onged sta t i c or repeated l oad i ng of musc l es
an d ten d o n s . S tat ic l oa din g can lead
(0 ischaemic muscle pain and
l oca lised fa t i gu e , a nd repeti t i ve tasks can cause micro-trau ma ( S m ith
1 996) It is the pain o ft en Ce l t in the shou lders, a rms , wrists and fi ng e rs 0 1 c l erical workers who, i n sustained p o s t u re s , perform the
same task fo r (00 l o ng w i t h o u t i n terru p ti o n or variation . It m a y b e th e resu lt o f excessive mec h an ical stra i n o n t he structure resu l ting i n
de lo rm a t i o n of t he co ll a gen fib res and pressu re on t h e free nerve endi ngs withi n ( B ogdu k 1993) A l t e rna tively, in contra c t ile stru c tu res unde rgoi n g con s tant con trac t ion w i thou t brie f periods of relaxation, s y m p toms m a y be t he prod u c t of ischaemia ( N ewha m 199 1 ) I n t ramusc u la r p ressu re d u r i ng a c ti v i ty can compress the blood vesse ls , i m p a i ri n g the re moval o f m e t a b ol i t e s a n d t h e supply of o xyge n , ei th e r 01 w hi c h may produce temporary pain ( Mense 1997 ;
N o r ris 1 993 , S m i t h 1996)
N o tissue d a m a ge has o c c urred as
movement or a cha n ge o f posi tion removes the pa in as the c ircula ti on re tu rns a n d the m e ta b o l i tes are flushed a way. These p ostura l pains are thus produced by sustained mid-range activity in which abnormal st ress is placed upon nonna l contrac tile struc tures.
Howe v e r, con t i nu i ng repeti t i on o f static tasks be gins to take i ts t ol l , and tiss u e d a m age ca n occ u r (Smith 1996) . F o r in s t a nc e , p a in may be fel t
in
the s h o u l d e r from e xcessive performan ce of overhead tasks.
This activity causes hig h in t ra m u scu lar pressu re in the rotator cu ff musc les w h i c h c a n i m p ai r l ocal circulation , a l ready compromised by c o m p ression o r t he tendon under the acromion . I nitial l y there is cell ular dcgeneration an d i mpaired vasc u l a rity, wh ich may cause pain tha t abates whe n the a c t i v i ty ceases. However, i f su c h loa d ing is
1 33
34 1 C H A rT E R Tvv o
T H E H U IvI A N E X T R E IvI I T l E S : M E C H A N I CA L D I A G N O S I S & T H E RA PY
repeated fo r many h o u rs on a d a i ly b asis , t he degenerated ce l ls or ischaemic state can give rise to a n in flamma tory reaction , a n d
a
constan t pain ensues ( G r ieco et a l . 1 9 9 8 ; M e ns e 1 9 9 7) L o ca l s t ra i n o n muscles can thus p ro d u ce ischaem i c e ffects w ith t i m e and l o a d ,
as wel l as acute mechanical fail u res If the stra i n is p rolonged loca l hypoxia , u ltrast ructural ru p tures , energy depletion , a n d cell d e a t h m a y i n d uce sym ptoms ( H er b e r t s e t al 1 9 8 4 )
A l te r n a t iv e l y,
hy povasc u larity may lead t o degene ra t i v e c han g e s in ten d o ns so t ha t in a weakened state , the tissues are p re disp ose d to e a rl y fa i l u re
pain , an d p r o gn O S i S i s p o o re r ( H e r b e r t s e t al 1 9 8 4 )
,
and
Te n d o n
degenera t i o n c an be severely symp t o m a t i c or entirel )l silent, w i th various aetiological fac tors b e i n g i m p o rtant in its pa thoge nesi s , but red u ced vascu l a rity and impai red meta bol i c ac t i v i t y c r u c i a l I n this respect ( K an nu s et a l . 1 9 9 7) It h a s been p r o p ose d t h at a seden tary li fes t yle may cause poor c i r c ul atio n in te ndons and so p re d i s p o se to chronic d isorders ( Ka nnu s e t a l 1 9 9 7) D a mage , if c o n fined to fib res of t he muscu latu re , is u n l i k e l y to lead t o lo n g te r m problems . T he excellent vascularity p r o v id e d to m usc le -
e nsures ra p i d repai r fo llow i n g all but the m o s t seve re i nj u ries H o w ever if the s t r a i n a ffects t he less vascu la r fi b rous t e nd o n s ,
,
a p o n e u r os e s o r pe riostea l inse r t i o ns , there i s more l ikeli hood o f
p e rsistent p roblems resultin g Tendons a re renow ned sou rces of chronic symptoms in a wide range o f up per- and lowe r- l i mb diso rd e rs H y poxic degeneration an d innerv a t e d i m m a tu re g ran u l a t i o n t issue seems to p ro duce pro l o nged p a i n and i m p a i re d fu n c t io n w h i ch ,
IS
h i ghly resistan t to fu ll recove ry (Leadbet[er 1 9 9 2 ; G ross 1 9 9 2 ) This is n o t ch ronic i n fl a mm a t ion , as i n fla m ma t o ry cel ls a re n e v e r fo u n d in this d e ge n e ra te d tissue (Verhaar e t a l . 1 9 9 3 : C h a rd e t a l . 1 9 94)
Thus du r i n g the early stages of the s y m p L o m s , d i sco m fo rt o r pain ceases e n t i re l y on c e the o ffen d i ng p os i t io n is changed With c o n t inu e d p r olo n ged or repe ti tive load i n g o ve r m a n y m o nt h s w i th o u t a de q u ate rest p e r i o d s or relaxation of the m usc le , m ic ro - tra u m a may res u l L a n d a n i n fl a m ma t o r y respon se is t r i gge re d w h i c h is n o l o nge r amena ble to rest o n ly. Cum u l a ti v e trau ma , r a L h e r t ha n a discre t e trau matic event , thus b r i n gs abo u t patholog ica l c han ges (S mith 1 9 9 6 ; T h o rso n a n d S z a b o 1 9 9 2 ; Yassi 1 9 9 7) A l te rn a ti v e l y cu m u l a t i v e strains c a n p ro d u ce o c c u l t d e ge n e r a t i o n i n t e n d o ns , w h i c h l e aves
t he m sus c e p ti b le t o fa i l u re , w i th a co rres p o n d i n g p o o r p rognos is
S O FT
T I S S U E P R O P E RT I E S
C H A I ' TE R T w o
S u c h d isorders o f c u m u l a tive trauma a re the sec ond most fre q u en t ly re p o rted ca t eg o r y of occu pa tional d iseases a fter skin d i s ea ses (Th o rs o n
a n d S z a b o 1 9 9 2 ) S t rains du e to r ep e t i t i v e a c t i v i ti e s c a n o c c u r in t h e
h a n d s , wris t s , e lb o w s , shou l ders , neck, back , h i p s , knees and an kles , wi t h u p pe r- l i m b re p e tit i v e s train i nJ 1.ui e s b eing one o f t he fas t e s t
g ro w i n g gro u p o f occu pational d is o rd e rs (Yassi 1 9 9 7) Th e u pp e r l i m b is
v e ry
c o m m o n ly a ffected b y t h e consequences o f pro l o nge d
o r re petitive l o a d i ng . Sy m p t oms c a n b e re p o n e d i n the should e r
(bu rsitis o r t e n d o n i t is) , the elbow (medial and la te r a l e p i c o nd y l i ti s ) , the w rist
an d
th u mb (tenosynovi t i s ,
w r i t e r 's
cramp , de Quervain's
s y n d r ome , c a r p a l t u n n e l s y nd ro m e ) . A c a u s a t i v e ro l e h a s b e e n a ttri b u t e d t o re petitious w o r k ; unusual , constrained o r s t a t i c postu res : a n d ex posure to v i bra ti o n a n d e x t re m es o f tempera t u re P e o p l e who ad o p t e x t re m e
j O int p o s i t ions a re at risk , and those who w o r k
in
po s t u re s re qu i r i ng e xcess i ve s h o u l d e r ab d u c t i o n , 'vv ris t O e x i o n or ra d i o u ln a r d e v i a t l o n a re a t h i gh r is k of d e v e l o p ing t e n d o n i tis . F a u l ty
worksta t i o ns and e q uipme n t a r e a l s o a ggr a v a ti ng fac tors (Thorson and Szabo 1 992: Smith 1 99 6 ; H u s k i sso n 1 99 2 ) K e y b o a rd o p e r a t i v e s a re
fre q u e n t c o m p l a i n a n t s o f s u c h d is o r d e rs , bu t the pre v a l e n ce o f
neck and a r m pains a p p a re n t l y rel a t e d t o o cc u p a tion a re c o m m o n across v a r i o u s i n d u s tries ( B u c k l e 1 9 8 7 ; B y s t r o m et a l . 1 9 95)
P ro l o n ged a n d abn o r m a l post u ra l stresses t h us h a v e a ro l e i n t h e p a t h ogenes i s oj
v a r i O llS m usc u l os h e l et a l c o n diti o n s . F u rt h e r m o re ,
d y n a m i c p o s t u r a l fo rces are sign i fi c a n t in many o f these c o n d i tio ns . For i ns t anc e , p a i n can sometimes p re v e n t abd uction o f the sho ulder
i n t h e p resence o f a ro tato r cu ff d i sorder, whi le a b d u c tion is possible w i th t he arm la t e ra l l y ro ta t e d . I n d ivid uals with lateral e p i co n d y l i tiS
can find l if t in g w ith the a rm su p i n a t e d c o n siderab l y more p ainful t h a n lifti ng w i th t h e a rm p ro n a t e d Patie n ts wi th a n t e ri o r knee pa in ,
who ge t pain d esce n di n g stai rs o r s i t t in g fo r l o n g p e ri o d s b e cause the p a te l l a i s m a la l i g n e d , a re p a i n - free o n ce this p o s t u r al s t ress is re rn o v e d .
T hus s t a t i c a nd d ynamic p o s tura l fo rces a re c l early re l e van t
W i l h m a n y c o n d i t i ons a n d n e e d a d d r essi n g
in t h e i r management
Cli nical i m pl ications Damage to s o ft t issues may be the result o f a traumatic e ve n t , but eq u a l l y c a n o c c u r w i t h the c u m u la t ive o verlo a d of rep e l i t i v e s t ra i n ,
a b n o rm a l s u s t a i n e d p o s t u re s or degenera t i on o f t iss u es . Excessi v e external o r i n ter n a l fo rce s c a n t h e re fore p ro d u ce m e c h a n i c a l s tr a i n
1 35
36 1 C H A r T E R T w o
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H U M f\ N E X T R E M I T I E S : M E C H A N I C A L D I A G N O S I S
& T H E Ri \ P Y
a n d tissu e d a m age . Any da mage that o cc u rs to s o ft tissu e s u n leashes the in fl a mmatory resp onse , the fi rs t stage on t h e road to re covery This is fol l o w e d by t issue repa i r and remo d e l l in g i f a l l go e s wel l . The en tire process cannot be avoided o r speeded u p , but i t can be impai red and inapp ro p r i a te behav i o u r can prevent t h e re mod e l l i n g , whi c h sho u l d re t u rn the tissu e s t o n o rm a l fun c t i o n . M e c h a n i c a l fo rce s a re essential to this process a n d s o me t i mes igno rance , b a d a d v i ce or fear of d o i ng fu rth e r d amage constra ins i nd i v i d u a ls fro m d o ing what is b e s t . I n certa in i ns tances the p ro cess of re p a i r seems to ge t ' s t u c k ' , leav ing t i ss u e t h a t is i m m a t u re , p a in fu l and n o t c o n d i t i o n e d fo r n orma l use . This m a y be t h e re s u l t o f fai l u re to re m o d e l a d e qu a t e l y, o r d u e to an a b o r t e d rep a i r process o r u n de rl y i ng d e ge nerative
c h a nges in the tiss u es - tend o ns are particu l a r l y p rone t o p e rsis t e n t symp t o ms i n this way The p e r i o d when rela tive re st is a p p ro p r i a te , d u r i n g the i n fla m m a t o ry stage , is very sho rt . Progress ive exposu re to mec h a n i c a l l o a d i n g s h o u l d
s t a rt ea rly
I n fa c t , a l a rg e p r o p o r t i o n o f p a t i e n t s s e e n b y
physi o t h erapists a re seen a t a much l a t e r stage w h e n re st i s a b so l u tely
c o n traindica t e d . Repair h a s usually occu rre d , but pain and i mp a i re d fu n c tion rema i n . Only t h ro u gh e x p o sure to mecha nica l l oa d i n g c a n re m o d e lling o ccur, deconditione d s t ru c tures be ma d e fu n c t i o n a l a n d sensitise d tissue b e made n o rm a l . T h is i s o n ly a c h i e v e d w i th regu lar exe rcise that chal lenges t h e u n fit t i s su e . N o p i l l , l o t i o n or e l e c t rolllc
ga dgetry can even begi n to p ro mo te this change , a n d to p re t e n d o t h e r w i s e i s t o c o n d e m n p a t i e n t s t o c o n t i n u e d s u f fe r i n g I m p rove m ent in t h e state o f the s t ructu re and t he c o n fidence o f t h e p a t i e n t to use i t can o n l y b e b ro u g h t about b y gra d u a l l y e x p o sing the tissu e t o l o a d ing a n d m o ve m e n t .
C H A PT E R T w o
S O FT T I S S U E P R O I ' E ln l E S
S ir Astley Coope r ' s eng ravings The ['o l l owi n g e ng ravi n gs w e re take n from the work of S i r Ast le y Coo p e r w h o p ra c t ice d his profession a s a S u rge o n in Lon d on fro m t h e l a te 1 7 0 0 s t h ro u gh to a b o u t 1 8 3 0
The engravi ngs show t h e
re marka b l e c a p a c i t y of n a t u re to heal e v e n the most severe i nj u ri e s
a nd th ro u g h the p rocess o f re m o d e l l ing re s t o re fu nctio n ; pe rh ap s not e n t i re l y b u t a d e q u a te l y in most cases . ,
T h e p ro cess of re m o d e lling c a n o n ly be achieved thro ugh p er sis te n t a n d regu lar m o v em e n t . The exa m pl e s tha t fo l l ow a re fro m a wid e ra nge o f articu lar s pe c ime ns and show re mod e l l ing of bone a n d s o ft t issu es s u c h as te nd ons , l i g a men t s ca psu l e s and c a rtilage . ,
C o o pe r d i d n o t enJ oy the bene fits of modem te c h nol ogy a n d methods that a re now availab le fo r the d e te c t i o n and re d u ction of disl o c a tions a n d fr a c tu re s The natu ra l p ro ces ses of h e al ing as de monstrated in t h e [o l l o w i n g s p e c i m e n s a re ra re l y s e e n t o da y. H o wever, they d e m o nstrate t h e p owe r that normal functional act i vi t y has to re mod e l bone a n d so ft t issue , in even the mos t ex treme cases , and p rod u ce
wor ki n g pse u d o-articulations. The sel ected text a nd e ngrav i n gs shown here are u nch a n ged from the o rigi na l
Treat is e on D is l o c a t ions and FractLlres oj t h e JOints . S i r A s t l e y Coo per, BART FRS . S er g e a n t S u rgeon to the K i n g P r i n t e d
in
1 83 1 .
Seve n t h E d i t io n printed by Messrs Lo n gm a n Ree ce , Vaughan ,
B rown a n d G re e n , Pater noster Row, Sou t h Highly, 1 7 4 Fleet St.
D rawn a n d en g ra ve d by C] C a n t o n , p u b l is he d b y A s t l e y Co o p e r 1 8 2 2 . ,
137
38 1 C H A PT E R Two
TH E
H U MAN E XT R E M I T I E S : M E C H A I'i I CAL D I AG N O S I S
& T H E RA PY
P l ate I I Shews a d isloca ti o n into the fo ramen ovale which had never b e e n re d u c e d and beau t i fu l ly e xh i b i ts t h e re s o u rces o f n a Lu re i n fo rmi n g a new socket fo r the head o f the b o n e and a l l o w i ng of the re stora t i o n o f a cons i d e rable degree o f motion . H
-
The new acetabulum formed in the fo ramen ova l e
i n vv h i c h t h e
h e a d o f t h e t hi gh b o ne was c o n t a i n e d a n d in vv h ich i t was so comp lete l y enclosed t h a t it became impossib le to re move i t un less a p o rt i o n o f t h e n e w s o c k e t was b ro k e n a w a y I t was l i n e d by a l i gamentous substance on which the h e a d o f the bone moved to a conside ra b Ie exten t . 1
-
The origi n a l acetab u l u m s i t u a t e d above the l e v e l a nd to the o u t e r
siele o f t h e new c a v i ty
S O FT
C H A PT E R
T I S S U E P RO P E RT I E S
'
....
;• . 1 1
Two
1 39
I
40 C H A PT E R T w o
T H E H U M A N EXT R E M I T I E S : M E C H A N I C A L D I A G N O S I S & T H E RA rY
Plate I II E x h i b i ts ano t h e r vi ew o f t b e same pre p a r a t i o n shewing the re l a tive s i t u a ti o n and a p p e a rance of t he new and the o r iginal a c e tabu l u m .
B
-
The o r igina l acetab u l u m li t tl e more than ha l l iLS na t u ra l size , L h e
e d ge of the new ace t a b u l u m occu p yi ng i t s lowe r and anterior part .
C
-
The new acetabu l u m fo rmed in the fo ra m e n ova l e , a dee p ossi fic
edge surro u nd i ng i t . I ts i nt e rn a l su r faces e X L remely s m o o t h . The ligament o f t h e fo ramen o v a l e h a s d i s a p peared a n d os s i fic matte r has been de p osited in i ts stea d .
D
-
The thigh bone removed and a port i o n of the ne w acetabu l u m is
shewn whic h was obliged t o be b roken o ff to s e parate t he thigh b o n e fro m i ts n e w socke t .
E
-
Head and neck of t h e thigh bone ; t h e fo rme r a l i ttle cha nged b y
absorption and t h e l a t te r by ossi fic depos i t .
C i-I A I'T E R Two
S O F T T I S S U [ P R O PE IH I E S
" I. I I I ,
--
I)
1-..
1 41
42 1 C H A rT E R T w o
T H E H U M A N E X T R E M I T I ES: M E C H AN I CAL
D I AG N O S I S
& T H E RA PY
P l ate IV Shews a d isl ocation in t h e ischiatic no t c h . T h is is a s i d e v iew o f the exterior surface o f t h e os inom ina t u m .
G
-
Shews a neyv capsular ligament fo rme d a ro u nd t he head o f the
b o n e a n d c o m p o s e d o r c e l l u l ar m e m b ra n e c o n d e n sed b y i n flamma t i o n .
S O FT T I S S U E P RO I' E RT I E S
C H A PT E R
.\
II
Two
14 3
441 C H A PT E R T w o
T H E H U M A N E X T R E M I T I E S : M E C H A N I C A L D I A G N O S I S & T H E RA PY
P l ate V
Exhib i t s a view of the dis l o cation o f t h e o s fe m o ris upon the pubes o r fo rwa rd s and u p ward s . This p reparation b e a u t i fully shews the power o f n a t u r e E F
-
-
m
accommodating i tsel f to new ci rc u mstan ces .
Trochan tor m aj or o c c u p yi n g the o rigina l ace t a b u l u m .
Head anel n e c k o s fe moris u p o n t h e J u n ction o f t h e p u bes and
ili u m G
-
The new c u p fo rmed for the neck of th e o s fe m o r is
C H A PT E R T w o
S O FT T I S S U E P RO P E RT I E S
I ' I . ,\.
1 45
46 1 C H A PT E R Two
TH E
H U M A N E X T R E M I T I ES:
M EC H A N ICA L
D I A G N O S I S & T I-I E RA I 'Y
P l ate VI Sh ews [he same pelvis, wi th the thigh bone removed fro m it, t o ex pose [he new acetabulu m fo rmed by ossific in flamma tion i n the j u nc tion of the pu b i s and i lium .
D E
-
-
Aceta bulu m , which was occ u p i e d b y the troch a n te r maj o r.
F The new ace tab u lu m .
C H A PT E R T w o
S O F T T I S S U E P RO P E RT I E S
1 ' 1 • . 1' 1 .
.\ .\
[ 47
48 1 C H A PT E R T w o
T H E H U ,\;\ A N EXT R E M I T I E S : M E C H A N I C A L D I A G N O S I S & T H E RA I'Y
P late XXI I Fig
1
Shews the new socket which ha s been fo rmed on tIl e i nner s i d e o f t h e in fe ri o r c os t a of the s c ap u la i n a d i sloca t i o n o f the os hu m e r i into
the a x i lla . G
-
The new socket fo r the hea d o f the os hu meri .
Fig 2 D
-
N e w smo oth cavi ty for t h e head o f the os h u m e r i
-
which
extended fro m t h e edge o f the gl e n o i d cavity t o the coroco i d p rocess of the sca p u l a .
S O FT
C H A rT E R
T I S S U E P RO P E RT I E S
1' 1 . . 'X.\ 1 1.
Two
1 49
50 1
" T E R Two
E H U M M J t X T RE M I T
D I AG
" & TH E k
Plate X X I I I Fig 1 Dislocation o f the os humeri fo rw a rds u n d e r the clavlca l a n d b e h i n d pectoral m u sc l e . f - Portions o f t h e n e w hgament which encl o s e the head 01 t h e bone
- The rown .
cd glenOlu cavi ty,
w h i ch
hu rner:
been
S O FT
TISSUE
P RO P E RT I E S
C H A PT E R
!'I
\..\ ) 1 I
Two
1 51
52 1 C H A PT E R Two
TH E H U MAN
E X"f RE M I T I
CA L D I A G N O S I S & T H E ll.'\
P l ate XXV Fig
1
Dislocation O f !
Ina backwards
Fig 2 i t s p ressu re
condyle of the o s h u m e r !
aga i ns t
a socket the re fo r
mal
C H A PT E R T w o
S O FT T I S S U E P RO P E RT I E S
i 'L . !i.X Y .
F./(;
OJ
1 53
54 1 C H A PT E R Two
T H E H U M A N E X T R E M I T I E S : M E C H A N I C A L D I A G N O S I S & T H E RA I' Y
P l ate XXVI I Fig 2 E
-
E x t e r n a l condyle fra ctured e x terna l l y to the capsu la r liga ments ;
great a tt emp ts by n a ture to unite i t , and the form o l the bone changed .
Fig 3 G
-
The new l igament w h i ch has j oined t h e o lecranon to the u l n a r
C H A rT E R Two
5 0 1' 1 T I S S U E P R.O I' E RT I E S
FI' ; . )
('
1 55
I h l' l l l �
1\
C H A rT E R T w o
S O FT T I S S U E f' R O I' E RT I E S
]'1. . • ,7] J , F/ (:
1-"1 1,
.... .,.
!
1 57
58 1 C H A P T E R T H RE E
T H E H U MA N EXT R E M I T I ES: M EC H A N ICA L D I AG N OS I S
& TH E RA PY
CHAPTER THRH
3: Pain
Introduction Patients' prime concern is usually pain, although secondary to this may be concern with loss of function. It is important to have some
ground rules by which to interpret and understand pain and the state of painful tissues so that the appropriate active management strategies can be implemented This chapter looks at different causes
of pain and relates these to the state of the tissues. By recognising
typical patterns of pain behaviour early
in the treatment process, we
can predict those who will respond to certain management strategies. Atypical or partial responses will identify those patients with problems that are not going to fully resolve that require improved self management strategies or may need a multi-disciplinary pain management approach. The clinical implications of these issues will
be discussed.
Pain and nociception The means by which information concerning tissue damage is experienced and transmitted to the cortex is termed nociception Most tissues in the body possess a system of free nerve endings nociceptors
-
-
which are activated if a noxious snmulus is experienced,
thus triggering the nociceptive system After tissue damage is detected this information is transmitted via the peripheral and central nervous system to the cortex and provides the means by which we are made aware of pain. En route the nociceptive message is modulated; that
is, the central nervous system, including the higher centres, can exert inhibitory or excitatory influences on the nociceptive input (Bogduk
1993) Pain has been defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or des cribed in terms of such damage" (Merskey 1991) This widely accepted and mucll. quoted definition recognises that the experience of pain is a conical phenomenon influenced by affective and cognitive factors as well as sensory ones (Bogd u k 1 9 93) This definition also distinguishes between the experience of pain and the physiology of nociception. The implication to clinicians of this modern concept of
159
601 CHAPTER THREE
THE HUMAN EXTREMITIES: MECHANICAL DIAGNOSIS & THERAPY
pain 1S that our management must enco mpass patients' responses to pain, as well as their sensation of pain. It is important to recognise that the
experience of pain involves
patients' emotional and cognitive reactions to t b e process of nociception Many issues are relevant here - patients' anxieties, fears
and b eliefs may strongl y determine their response to injury, pain and treatment Fear of pain and re-inJury may lead to avoidance of .
a c ti v i t i e s that they believe will do more 11arm. S uch lacl< of
u nde rst a nding of theiT condition ca uses inappropriate action in the face of pain and p roduces feel i n gs of limited ability to control or
affect the condition. Su c h avoidance in the long term will have a d elete ri ous effect on the patient's recovery (Philips 1987) These
factors can be addressed by prov i d in g patients with a thorough understanding of their problem and educating them in the appropriate
use of a ctiv ity and exercise to rega in function and reduce pain
F acilita ting pat i e nts' control over the iT problem, encouraging a c tive coping strategies and h e l p ing them confront their fear of pain should all be part of management ( t
well as the condition itself. Failure to grasp this multifactorial, biopsychosocial model of pain and see it only as n ocicep ti on leads to a failure to understand pain
The difficulty that researchers and clinicians have in g r a sp ing this con c e pL is illustrated by the following comment: "It is a marvel to me and a tribute to the persistence of selective attention that so many health care researchers seem unable to come to grips with what has been well hnown and repeatedly demonstrated: namely, that humans
and the complex behaviours they emit can be understood only by conSidering their biomedical, gen etic psychological, and environ ,
mental/social contexts. To do less is to perpetuate a myth. Pain, particularly chronic pai n is transdermal. Put another way, perhaps ,
pain ought /.0 be seen as a verb, not a noun" (Fordyce 1999)
Sources of pain Any tissue which co n ta ins the free nerve endings involved in noci ception is cap a ble of being a sou rce of pain. In re lati o n to
peripheraljoint regions, nociceptors are locate d in the Joint capsules
CHAPTER THREE
and ligamems, articular fat pads, perivascular sites, bone, periosteum, muscle s and tendons, but probably not in Lhe Joint cartilage (Zimmermann 1989) The skin and subcutaneous tissues are also richly innervated (Williams and Warwick 1980) Bursae, fasciae and aponeuroses are also possible sources of pain, although the literature on their innervation is scant.
Two types of tissue are the main sources of musculoskeletal problems - muscles and connective tissues. Connective tissues include tendons, aponeuroses, fasciae, ligaments, bursae, synovial and intra-muscular sheaths,Joint capsules, cartilage and bone. Cyriax (1982) referred to contractile and non-contractile stllJctures, contractile tissues being: muscle belly tendon tendon-bone interface Non-contracLile tissues include joinl capsules ligaments bursae nerve roots dura malers fasciae
Activation of nociceptors Only three mechanisms are known by which nociceptors can be activatecl- these are mechanical, chemical or thermal stimuli CBogduk
1993; Zimmermann 1989)
It is the first two that are our concern
here. In normal circumstances the sysLem of nociceptors are inactive, but as the stimulus crosses the threshold into the noxious range, the nociceptive process is triggered. This may be due to the application
of mechanical forces that suffiCiently stress, deform or damage tissues as would occur with prC'ssure, distraction, distention, abrasion, contusion or laceration. The nerve endings may also be activated by
their exposure to certain chemical substances present in the
161
621 CHArTER. THREE
THE
HUMAN EXTREMITIES:
MECHANICAL DIAGNOSIS & THERAI'Y
surrounding tissue fluid following their release from traumatised, inflamed or necrosing tissue. Pain arising from trauma is produced by a combination of mechanical deformation forces and noxious chemical irritation CBogduk
1993).
Initially, mechanical deformation causes damage to soft tissues and pain of mechanical origin will be felt. In most cases this is a sharp pain (Melzack anel Wall
1988)
When mechanical deformation is
severe enough to traumatise soft tissues, it may be the result of
an
external force; it could also result from internal force, as in a sudden uncoordinated movement. Common examples mighL be spraining an ankle ligament when slipping off a pavement edge, falling onto an outstreLched arm, a kick or blow during football or straining a
calf muscle when playing tennis. Excessive external forces can cause certain conditions. However, patients will frequently develop musculoskeletal pains without any appreciable trauma. When asked for their luslory, Lhey will report that the pain came on for 'no apparent reason'. Diverse conditions such as shoulder capsulitis, supraspinatus tendonitis, lateral epicondylitis or tenosynovitis at the wrist are all known to start inSidiously without a single traumatic mcident The pain relaLed to joint degeneration is also more likely to start in a gradual way Pain of insidious onset is more likely to occur following age-related changes. These cause a decline in musculoskeletal function, increasing the vulnerabHity of the tissues to injury and leading to slower and less effective healing (Buckwalter et al.
1993)
Mechanical stresses sufficient to cause trauma do not always arise from the application of abnormal external forces. Prolonged constant
or repetitive loading repeated over many months or years mighL eventually cause cumulative tissue damage. Forces may become abnormal when the duration or repetitive nature of the applied force is excessive. Excessive internal forces can therefore cause certain conditions The nociceptive system can be activaled by excessive mechanical stresses over long periods of time, by actual trauma, or by the chemicals associated with the inflammatory process. The degenerative process, which commonly occurs in peripheral Joints and soft tissues,
CHAPTER THREE
can stimulaLe noc ice p to rs by both me chanical and chemical irritants related LO lhe pathology (Zimmermann 1989) Because the cause 0[' pain is an important determinant of t h e appropriateness of mechanical therapy, it is viLal to distinguish be t we e n mechanical and chemical sources of nocicep tion We can
begin to d i stinguis h between these types of pain by certain factors gained during the hislory-taking and largely confirm this i mpression durin g the physical examination.
Differentiating between chemical and mechanical pain A key characteristic which indicates the p ossi bility
of pai n of chemical
origin is constant pain. Not all constant pain is inflammatory in nature,
but chemical pain is nearly always constant. The term 'constant pain' indicates that the patient is never without an ache or d iscomfort from the moment they wake until lhe moment they fall asl eep. The ache may be exacerbated by movements and be less at times , but the dull, rele ntless ache never goes away e ntirely. Constant pain may resu l t from chemical or mechanical causes, or be due to the changes associated with chronic pain . A description of the cause and behaviour of constant chemical and mechanical pain fol lows .
Constant pain - chemical cause (Constant Chemical Irritation) Cause and onset Pain 1S prod u ced by che mica l irritation as soon as the concentration of chem ical substances is su ffi cie n t to irr itate free nerve endi ngs in the in v o l ved soft tissues. Such chemicals include h i s tamin e , bradykinin, serotonin, hydrogen and potassium ions. They are released by cells in damaged tissue or by inflammatory cells follOwing tissue d ama ge, and thus chemical nociceprion only occurs with actual tissu e d amage CBogduk
1993)
Systemic disease or infection can also
cause Lhis inflammatory p rocess - for i n s tance , with active rheumatoid arthritis, an ky losin g spondylitis, tuberculosis or other bacterial
i nfections . Treatment of i n flammatory arthropathies lies outsi d e the sco pe of this text. Our prim ary concern here is the inflammatory
process that occurs in the first week or so follOWing trauma.
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641 CHArTER TIWEE
THE HUMAN
EXTREMITIES: MECHANICAL
DIAGNOSIS & THERAPY
An insidious onset of symptoms, witho u t a pparent trau ma, d oes not
di scount an inflammatory comp one n t to the p roblem This i s more likely to occur when tissues are in a weakened sta te due to unseen degenera t ive cha nge s or overuse. For in s t ance can produce in fl a mma to r y 1989) Capsulitis of the shoulder
degeneration (Zimmermann
,
gradu al a rthritic mediated is th o ugh t
pain
to have
an early i n fl a mmatory stage, and frequ e ntl y has a non-traumatic on set
(Stam 1994) Su st ai ned or re peat ed activities can l ea d to micro-t rauma of soft tissues and ins idious onset o f conditions such as l ate ral epicondylitis (Bind er and Hazleman 1983)
Behaviour of pain Chemica l irri tants d o not appe a r and di sa ppe a r during th e course of the day Pain of chemical origin is constant, and t herefo re pa tien t s
who experien ce periods of the da y when no pain is present or who describe that cenain p os it i ons a re p a i nl ess do not have pain of
inflammation. Adopt ion of a cert a in pOSition that stops all pain excludes the p ossi bil it y of a chemical or inflamrnatory condition.
T h e desc ription of intermittence imme diate l y excludes chemical
or
inflammatory origins for musculoskeletal pain. The provocation of
sy mptoms only as a re sult of mechanical l o a d ing exc l u des infl a mm a tory causes and allows for a com plet e ly mechanical a ppro ach to diagnosis and treatment. Just as t issue d amage al w ay s causes inflammation, so inflammation
always causes the tissues to become h yperse nsitive (Levine and Taiwo
1994)
The inflammatory i rrit a nt s sensitise the local pain receptor
system and lower the thresholds at which the system is triggered to
creat e a state of pe r iphe raI sensiti sa tion (Cousins 1994; Woolf 1991) '
'
In thi s situa tion the a pplication of relatively minor m echan i cal stresses
causes pain that u n d er normal circumstances wo u ld
not occur
-
allodynia; noxious stimuli create e x aggerated responses - primary hyperalgesia; and there ma y be a sp read of hyper-responsiveness to
non-injured tissue - second ary hyperalgesia (Cousins 1994; Levine
and Taiwo 1994). Thus, at this stage, there will be aching at rest and exaggerated tenderness and p ain with touch and m o ve m en t (Levine
and Taiwo 1994). Thus, movement may supenmpose mechanical
forces on an existing chemic al pai n and increase it, bu t they wil l never reduce or a bolish ch e m ica l p ain
.
Thi s is sig n i fi can t in the
differentiation between chemical and mechanical pain. Repeated m o ve ments are likely to cause a lasting worse ni ng of symptoms.
CHAPTER Tt-IREE
Because of this heightened sensitivity there is a lack of correlation between mechanical stimuli and the intensity of the pain response it hurts much more than it should (Woolf 1991). When acute this response is normal, and it encourages protective, immobilising actions that are appropriate immediately after injur y and during the innammatory stage Rest at this poim has the important effect of reduClng exudate and protecting the injured tissue from further damage. The same response at a later stage of the healing process does not serve any useful purpose, but is in fact detrimemal. Only during the innammatory period are rest and relative rest required: this must be followed by early mobilisation to optimise tissue healing. [t is at this stage, however, when individuals learn the habit of avoiding activities because they hurt. 1f this habit is prolonged and individuals develop the habit of avoidance of painful movements then the repair process will be retarded, remodelling will not occur, normal function will not be restored and persistent symptoms are likely.
The aching \vill progressively lessen as healing and repair develop during the first seven to ten days alter injury. Inflammatory cells, which are the source of chemically mediated pain, decrease in numbers until by the third week after injury none are present (Enwemeka
1989) The patient will experience constant pain until
sllch time as the healing process has suffiCiently
reduced the
concel1tration of noxious irritants. The situation may occur during healing in which the level of chemicals falls below the threshold that triggers nociception, although tenderness would still be present Norrnal mechanical loads may suffiCiently irritate the tissues so as to
re-trigger a constant chemical ache Aching that abates but is easily reproduced may represent an interface between mechanics and a resolving inflammatory slate. If this is the case tenderness should still be present By two to three weeks, constant pain due to chemical irritation will have reduced in intensity and be replaced by pain felt intermittently only when the repair itself is stressed. Musculoskeletal symptoms due to inflammation need appropriate time-limited relative rest prior to mobilisation. Certain conditions can presem at an inflammatory stage when the value of mechanical treatment is limited, or later when the problem has become mechanical and responds well to treatmem. The assessment protocol described in laLer chapters is invaluable in determining whether pain is arising from the inflammatory process follOWing trauma, infection
165
66 1 CHAPTER THREE
THE
HUMAN
EXTRIMI.TIES:
MECHANICAL DIAGNOSIS
& THERAPY
or disease, Some p ro b lem s of recen t onset, which are aggravated by early attempts to encourage
m
ove m e n t may, following a li m i t ed ,
p er iod of rest or relative rest, then begin to respond to progressive
mobilisation The di agn os t i c elements of an appropriate mechanical evaluation allow the identification of mechanical and symptomatic disorders ame n ab le to mechanical therapy. It is important to recognise
that cle arly es t ab l ishin g the stage of the d i sorder is more i m p orta n t in determining management than a st ructural diagnosis Key factors in the identification of pain of an inflammatory nature
constant pain shortly after onset (traumatic or pOSSibly insidious) •
cardinal signs - s w el lin g , redn ess , heat, tenderness
lasting aggravation of pain in some or all m oveme nts no m ove men t found which reduces or abohshes pain,
Stage and status of disorder
The same conditions ca n d is pl ay chemical or mechanical sources of pain de p ending on the time of assessment - conditions often pass through di f fer ent stages Early after trauma or the insidious onset of
an inflamed joint, tendon, bursa or capsule, constant pain will be experienced d u e to the inflammatory nature of the condition, Later
on, when adhesions, scar tissue or stiff tissue become the main problem, intermittent pain is experienced only when the tissue is stressed, In the acute/sub-acute stage of the p rob l e m repeated ,
movements may cause a lasting increase in pain, and mechanical t h er apy must be applie d with caution, This represents an interface between c hemi c a l and mechanical pain, In later stages repeated
movements cause only a tran sien t production of pain, which im p rove s gradually on repetition, and mechanical therapy is appropriate This situation represents an entirely mechanical source of pain, The same disorder may present anywhere al ong this the time
continuum, depending upon at which the pa t i en t attends for treatment, In terms of
appropriate management the establishment of this pain behaviour is
more important than the structural d iagnosis
,
FollOWing trauma the ac ute inflammatory stage should last no more than fi v e days, although this may be prolonge d if the delicate heahng
tissue is re-traumatise d (Evans 1980) In some musculoskele tal
CHAPTER
r 1\1 N
conditions, such as lateral epicondylitis and supraspinatus tendonitis, the persistence of symptoms long after the normal healing period 1S said to be due to ch ronic inflammation (Gross
1992;
Perry
1992). In
fact, histological studies of chronic tendon problems have never found inflammatory cells (Verhaar et al. 1993; Nirschl
1992;
Chard et al.
] 994) Instead, in patients v,rith long-standing tennis elbow or rotator cufT disorders, the ch anges are degenerative and re p resen t a failed
allempL at repair and a response to the relative avascularity of the tendon (Fukuda et al. 1994; Chard et al.
1994)
Chronic
tendonop a th ie s appear to be d ue to hypoxic degeneration and very sensitive granulation Lissue rather than ongOing inflammation, with the orderly phased wound repair apparently absent or aborted (Leadbetter 1 99 2 ) The tissues are left mechanically and structurally compromised, de c o n d itio n e d [or normal use, an d hypersensitive to normal loading Management wi II also be gUided by the status of the condition - that is, whether it is improving,
w or
se n ing or unchanging.
In these
degenerated tissues in which hea li ng is suspended, the problem will be relatively stable and u nch an g i ng over a persi sten t period despite
normal use of the limb. In this instance temporary aggravation of the symptoms [or
a
few days may be necessary to re- st im u l ate the repair
process.
Constant pain - mechanical cause (Constant Tissue Deformation) Cause and onset Constant mechanical deformation of tissue containing p a in receptors will cause constant pain, which may vary in intensity but will never disappear Mecha n ica l pain is a less well understood phenomenon
because of the technical difficulties o( studying it (Bogduk 1993) It is thought to be the result of the defo rmation of collagen networks so that (ree nerve endings are squeezed between the collagen fibres with the excessive pressure pe rcei v e d as pain (Bogduk
1993)
As
long as applied forces remain to cause sufficient tissue deformation,
pain will be experienced This will occur most fr e que n tly because of internal derangement, dislocation and/or disp lacement of loose bodies such as sequestered cartilag e or meniscal tissues. Internal derangement alters the tension in the structures within or about the segment, increasing mechanical deformation in some tissues and
THR.EEI67
681 Ci-lAI'TER TH REE
THE HUMAN EXTREMITIES: MECHANICAL DIAGNOSIS
d ecreasin g it in others. The co n st a n t
&
THER)\I'Y
increase in tension result i n g
from the displacement p roduces constant pain that c ontin ue s until
the tension is decreased by redu ction of the de ra n ge m e nt or by ad apti ve c hange s occu rring with ti me in the su rro un d i n g soft tissues.
A l though a h is to ry of trauma \Nill frequently have occurred, onset ma y also h app en without appa ren t force. Th i s is more likely when
ti s sue s are in a we a ken e d state due to overuse or degeneralion. Behaviour of pain Som e mo ve m ents o r posi t io ns may be found t ha t reduce symptoms,
while o ther positions or m ove ment s may aggravate tnern. The term 'constant pain' mu st be u sed only when the s y m p t o m s are truly
constanc that i s, there is no time in t he day when pain or aching is not present. P ain must be c lass ifie d as 'intermittent' even if there is only hal f an hour in the d ay when the patient feels co m p l e t e ly pain
free In tha t half-hour th ere is no m ec h a n ical deformalion present .
and we must examine the c ircums tan c es
in wh i c h the patient is pa in
free and utilise this information for treatm e n t purposes It should be noted that p atients might a dopt a strategy whi c h b rings some relief
fro m pain but which do es nOl c a u se resolution. The information that the patient provides about aggravating and relieVing [a c tors may
help the clinician d evelop the appropriate strategy Const a nt pain of m e ch an ic al origin will be a ssocia ted with an o b st ru c ti on LO movement, and th e re fore an impa ire d range im pr ov e in line with the
-
this mechanical presentation should
sy m p t omati c p re se nt a t ion .
It is much more sim ple to treat a patient vvho has intermittent pain than o n e whose p ain is c o n sta n t and in whom mechanical
de forma tion is c o ntin u ous and pre sen t under a l l circ u ms tan ces .
Patients with constant pain are less likely to be able to provide clue s
as to the likely direction in which to provide therapeutic motion. When a patient expe r i en ces t ru ly constant pain, it c a n only be because
of an inn a mm a to ry response to existing disease or r e c ent inJUry, from so me form of internal derangement, or from 11ypersensitisecl neural tissues in o n g oing pain states. [f an unde rly i ng innammatory disease process is the cau se of the sym pto m s
,
pain will be c on s t a nt , all
repeated movements will ca use an i ncrea se in p a i n and no movement or position will be found that recluces or stops the pain . If repe a ted ,
movements or c e r tain posit ions can be founclthat reduce or stop the
PAIN
CHArTER THREE
pain, the cause ca nn o t be in f1 amm ato ry and must be a re s ul t of
internal derangement. Key factors in identifying constant pain of mechanical origin ce r t a i n repeat ed movements cause a la s t i ng reduction or
abolition of pain movements in one direction worsens sy mpt o ms , whereas
movements in the other d i r e c tio n improves them the mec h anica l presentation improves with the sym pto ms
Intermittent pain - mechanical cause (Intermittent Tissue Deformation) Cause and onset Intermittent pain cannot be chemical in origin
Intermittent pain
can arise from either pro l onged positiona l (or postural) causes a cting on n ormal tissue, or from mechanical stress ap p lied to contracted, abnormal or d i spl ace d tissue during movement. It is t h us the res ult
oj abnormal s tre ss e s on normal tissue, or normal stresses on abn orm al tissues. The development of a bn o rm al tissue is usually a consequence of i m p e rfe c t repair following injury The abnormal tissu e may be the
result of a pas t traumatic event such as twi s ti n g an ankle' and '
prod U C i ng
a
lateral lig a ment sprain, or pushing off too e ager ly at the
b eginni ng of the football seas on and c a u sing a calf muscle strain. Abnormal tissue can a l so devel op without a history of trau ma fro m rep e titiv e overload, c a p sul a r reaction when joints have been ir ritated or degenerative changes
Certain J o ints are also prone to developing lo ose intra-articular displacements; in the pe rip he ral Joints these are the knee and j a w ,
and the e l bow hip a nd tarsal Joints less frequently (Cyriax 1982) ,
The se loose fragments will cause pain zmd obstruction to movement when trapped between the joint surfaces. Mechanical pain in the musculoskeletal system may thus arise due
to three situations postu r a l pains due to excessive stresses on normal ti ssues normal s tre sse s on a bn ormally contracted or scarred t iss u e normal str e sses on an articular derangement.
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Behaviour of pain Pos tural pains - normal tiss ue
I t i s not n e c essary actually t o damage tissu e c o n taining pain re cep tors i n o rder to p rovoke p a i n ( B o gdu k 1 9 9 3 ; McKen z i e 1 9 8 1 ) . Pain o f m ec ha n i c a l ori.gin will b e experi e n c e d a s s o o n a s mechanical fo rc es
a p pl i e d t o innerva t e d stru c t u re s a re s u ffic i e n t to stress or deform free nerve e n dings c o n t a i n e d w i thin. P a i n w i l l d is a p p e a r w h e n the a p p lica t i o n o f tha t fo rce is term i n a te d , and t h i s o ften occu rs b y a me re change o f position . This is te rmed ' p h YSiological' or t rans i e n t p a i n I t warns the b o d y o f p o tential d a m age a n d i s c h a ra c t e rised by a c o rre l a tion with the mec h a n i cal s t ress pro d U C i ng the pain a n d lac k o f l o ng- term sequ e lae , as t h ere is no tissue d a m age (Wo o l f 1 9 9 1 : Woo l f et al . 1 9 98) A goo d e xa m p l e i s t he pain i n c u rred d u r i n g p rolo nged slouched s i t ti ng t hat d i s appears u po n s ta n d i n g u p ri gh t .
Similarly, wh en a If
fi nger i s b e n t backwa rds s lowl y, fi rs t
a s t ra i n 1 5
fe l t
a p o s i t i o n J u st s h o r t o f s t rain vvh i c h wou l d p roduce a c tua l t issue
damage is m a i n t ained fo r a fe w m i nu tes a m ild ac hing o cc u rs . If t h e finge r i s bent s u d d enly b y a p p l yi ng a brief, r a p i d e n d - ra nge fo rce ,
the
p a i n re c e p t o r system w ill be ac t i va te d i mm e d i a te ly, b U L briefly
Pain can e ve n tu a l l y appear a fter m o d e r a t e p ro l o nge d l o a d i n g o r can appear i mme d ia t e l y as a res ult o f sud den sho rt - l ived o v e rs t re tc h i n g . In b o t h c a s e s th e p a i n wil l cease on release o f s t re tch i n g . I n n e i t h e r case , h owever, i s d a ma ge t o t i ssue necessary to ca use t h e pain . The gre a t e r t he mecha n i c a l loading a n d d e fo rmatio n become , the grea t e r the inten s i ty o f p a i n . If the p a i n fu l p o s i tio n is prol o n ged , the p a i n will become more d i ffu se , w i despre a d , and d i ffi cult [ 0 d e f i n e a n d o ften e xpands d i stally ( H a rms- Rin gd a h l 1 9 8 6 : K e l lgren 1 9 7 7 ) . I f n o s t r uctura l damage i s c a u s e d b y s u c h l o a d i n g , o n re le ase a n d re tu rn to i ts no rmal res ting posi tion t h e p a i n w i ll b e c o me tess d muse , less w i d e s p re a d , mo re l o c a l is e d to i t s p o i nt o f o ri g i n and s o o n subsi d e s . Incre a s i ng p a i n i n te n s i t y a t t h e end -ra nge o f m o ve m e n t i n d i c a tes t he b e g i n ning of overs tre tching
F u r t h e r move me n t in the same
d i re c t i o n will resu l t in d a m a ge . A s in the case of t h e fi n ge r, fo r example , the J o i n t is o b v i o u s l y being m o v e d i n the wrong direction as the p a i n intensity i n creas e s , and in t h e corre c t ive d i re c l ion as t he pain intens ity decreases . The example demo nstra tes Lhat t h e use o f i n cre a sing a n d d e creas i n g l evels o f p a i n p ro v ides a re l i a b l e g u i d e in the choice of dire c t i o n in which to apply t h e r a p e u t i c m O L i o n .
PA I N
C H A rT E R T H R E E
As d i sc u ss e d i n t h e p re v ious c hap te r te m po ra ry pa in s may also arise ,
in c o n t ractile s t r u c t u re s because o f the acc u m u la t i on o f m e ta b o h tes i n t issues in wh ich high i n t r am usc u l a r pressure p revents an a deq ua te
blood su p pl y (Mense 1 99 7 ; Smith 1 996) Unlike the mechanical s tress on p e ri-a rticu la r s t r u c tu re s , as i n the finge r exam p l e , t h e s e s tresses w i l l be i n ph ysiological mid - range , o r at wha te ve r point in the range
t h e m u sc l e is wo rking a t , r a t h e r tha n a t en d r ange These exa m p le s -
.
demon s tra t e t h a t the e x perience o f pa i n i s not de p e nd ent o n the presence of patho logy or tra u ma . These p o s t u ra l p a i ns w i l l ari se from p e rsiste n t load ing a t mid rang e -
fo r c o n t rac t i l e s t ru c t u re s and end -range for peri-articu l a r stru c t u res . T h e y c o m e on gra d u a l l y, b u t w i l l go as soon as the p o si ti o n is altered
or the muscle re l a x e d , a nd m a y be t ri g gere d m o r e e a S i ly i f t he s a m e
p o s t u re i s re p e a t e d l y a d o p t e d . P a tients w i l l rarely p re se n t w i t h such c o n d i t i on s ; they lea rn t hat they only have to move out of that p o s iti on
a n e! t h e p a i n d isa p p e ars . T hi s d i s com fo r t is gen e rally accepted as some h o w 'normal ' ; i t does not pa rtic u l a rl y concern t h e indiv i d u a l a n d m e d i c a l h e l p i s r a re l y s o u gh t for i t .
A bnormal
tissue
P a i n a nsing fro m ab normal t i s s u e w i l l eve n tu a ll y con cern t h e p a t i e n t b e c au s e i t o c c u r s re g u l a r l y e v e r y t i m e t h e y u n d e r t a k e c e r t a in ,
a c t i v i t ies . I t a l s o d oes n o t ge t ' b et t e r' , as they ex pec t b u t remains for ,
m o n ths o r e v e n ye a r s g i v i n g them t h e s a me pain every time the y d o ,
t h e s a m e t h i ng . I t m a y ge t gradu a l l y worse w i th t i m e a s t h e c o ll agen c o n ti n u e s to c ontra c t I t may l i m i t the i r normal range o f mo v eme n t .
a n d t h u s p roduce fu nctional p roble ms . C a psul a r t i gh t e n ing a t the
s hou l d e r may make it im poss i b le to hang ou t the w a s h ing ; at the h i p i t may ma ke wal k i n g p ai n fu l a n d cli fficul t . O l d g r o i n or ca l f s t rains may p reve n t the r es u mp ti o n of prev ious s p o r t i ng a c ti vi ty. These ti ss u e a b norma l i t ies w i ll present wi th e n d - range p a in on s t re tching the
a ffe c ted tissu e . Abn o rm a l tissue may a lso b e revea l e d d u ri ng movement ra ther than at e n d - range
A l though th i s may b e the res u l t o f d e ra ngemen t o f
in tr a - a rtic u l a r s t r u c t u re s , u pon rep e a t e d m o ve m e n t s this shou l d ch a nge , getting e i th e r worse o r b e t te r. Pai. n t h a t ap p e a r s consistently
d u ri.ng m id ra n ge l o aded m o v e m ents ( p ain fu l arc) is most like l y to -
arise from cont ract i l e tiss u e s . Thi s m a y o ccu r when the a ffected t issue i s c o m p r ess e d or constri cted , as in l e s i o n s o f the ro tator cu ff. The p a i n may a rise o n stati c , resiste d , m id- r ang e tes ting , for instance w i t h
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T H E H U M A N E X T R E M I T I E S : M E C H A N I CA L D I A G N O S I S
&
TH ERA I'Y
resisted wr ist extension in lat era l e p icondyl i tis. The abnormal tissue wi l l be consistently pain ful u pon repeated m ovements, neither ge tting better nor worse, unchanging from one day to the next . The pain will cease when the offending position is released, but w i ll always reappear
in
that same positi on and at exactly the same point d uring
the range No ch emical t reatment w ill prevent pain that ari ses solel y from mechanical deformat ion of soCt t issues. When inter m i t Lent m e chanical pain is the main presenting sy mpLO m , drugs should never be the fi rst treatment of choice. Key factors in identifying intermittent pain of mecha nica l origin
in normal tissu e pain wi l l only be p roduced after p ro l onged loading in
abnormal tissue pain will be consisten tl y produced every
t i m e that tissue is loaded or moved i n a way that stresses i t
l oading involves end - range movements i n a b norm.a l p e ri an i cula r st ruc tu res a
re st r i c ted range of movement w i ll be p resent
loading involves force generation at any poi nt thro u gh the ran ge in abnormal contractile st ructures
there w i ll be a characteristic sym ptomatic response to loa d i n g strate gies
-
pain w i l l be p rod uced o n load i ng, but w i l l abale
when this is rel eased in tra-articular d erangem ents w il l show
a
prderence l·o r
movement in one d i rec tion In summary, persistent problems may be due to poor re p a i r t i ssue
t hat will need
a
remod el l i ng programme , or it ma y be d ue to
ani cular displacements.
In
intra
some degenerate d Lissues t he repai r
p rocess appears to have been suspen d ed or aborted . Some chroni c pain can be due to dysfunctional elements
in
the c en t ral n e rvous
sys tem , i n which tissues are hypersensitive an d decon d i t i o necl , and
when a graduated exercise program me is indi c a t e d . We will no w consider these scenarios in more detail .
C H A rT E R T H R H
PA I N
Fail u re to remod el repair tissue 1 t is a
m
i s t a ke t o th in k that o n ce repai r is c om p l e t e that p a i n w i 11
cease . It is a l s o a m i s t a ke to t h i n k that as long as pa i n persis t s , repair is i n c o m p le t e . Pain w il l be e x pe rienced until rep a i r is complete a n d fu nct i o n is m a d e fu l l a n d fre e T h u s , long a f t e r healing is c o mple t e
,
s t ru c t u r a l i mp a i rm e n t m ay c o n ti n u e to cause p ain on sta t ic l o ad i n g or wi t h load ing from move ment o r a c t i v ity Pain m a y persist lo ng a fte r h e a li n g is c o mp l ete i f the re pair itse l f is co n trac t e d a d he re n t , ,
im p i nge d o r su ffers from c o m p ress i o n b y constriction . I n the presence of i m pe r fe c t re pair, p a i n w i l l a p pear whe n e v e r mi d ra n ge l oa d ing o r -
end ran ge stress i s a pplied to t h e sho rten e d re pair, when a d h e rence -
res t r i c ts move m e n t , o r w hen a ffec te d tissue is i t se l f c o m p ressed as o cc u rs w h e n t e n d o n s pass t h ro u gh c o n s t r i c t i o n s or o v e r b o n y
pro m i nences . The we a ke n e d state o f the tis su e wil l a ls o leave i t prone to fu rther s t ruc t u ral fa i l u re . T h i s i m p e r fect re pair t i ss u e may fol l ow from a failu re t o a d equately re m o de l t issue d am age a f te r t ra u ma . E q u a l ly abnormal tiss u e can p resent as the c o nse q u ence o f various d e ge n e rative c o n d i t ion s s u c h as os teo a rthri ti s o r gleno - h u m e ra l ca ps u li tis These pro b l ems m a y .
p rese n t a t a l a te r s t age when tissue contractu re i s t he m a i n c a u s e o f p a i n a n d l o ss o f fu nc t i on - a sim i l a r re m o d elli n g p r o gramme i s necessar y A b no rma l t issu e i s a l s o fo u n d in c o ntra c ti le stru c t u res a s a c o nseque nce of ins i d i o u s o nset ovemse co n d i tio ns w h e n t h e rep a i r p rocess has bee n i n c o m p l e t e . C o n t ractile s t r u c t u res , l i ke a l l o t her muscu l oskeletal tissu e , m a y g o t h ro ugh the in fl a m m a t o ry a nd rep a i r s tages o f he a l i ng b u t n o t the ,
re m o de l li n g stage . Adhes ions , contracture s o r scar tissue may res u l t fro m move m e n t a v o i d a n c e a n d t h e c o n s e qu e n ces o f the re p a i r p ro cess
Th is m a y leave t h e m u s c l e o r tend o n w i t h a n o d u l e o f
a b n o r m a l t i ss u e t h a t i s se nsi t ised t o normal l o ading. I t m a y produce p a in when the mus cle is ca l l ed u p o n to c o n tra c t i f the muscle is ,
s tre tched o r whe n the sensi tis e d n o d u l e i s c o m p ressed b y o t he r
struct u re s . O ft e n this i s t h e res u l t o f imp e r fe c t repair tissue th a t has been i na d e quate l y re ha bili tat e d . in some i nsta nces in te ndon s , where degenera t i o n p re -e x i s ts , t h i s may re su l t from a n absent or aborted re p a i r p rocess . The fa il u re t o progress t hro u g h the no rmal phases o f heal i ng i s conseque n t u p o n i ntri n sic tissue p roperties, such as hyp o x i a o r d e ge n e ra tio n (Le a d b e t ter 1 99 2 ; B u ck wa l t e r
et al. 1 99 3 ) .
1 73
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T H E H U M A N E X T R E M I T I E S : M E C H A N I C A L D I A G N O S I S & T H E RA r Y
Tension o r co m p ression l o a d i n g o f this a b n o rmal tiss ue wil l cau se
p a i n immedi ately when the s tretch o r compression is a p p l i e d at the p o i n t tha t cha l l e nges th o s e p articu la r tissues . In p e r i - a r t i c u l a r s t ru c tu res we a re used to s e e i n g this pheno me n o n a t e n d - ra n g e . In con tract i l e tissu es this sca r tissue wi l l be ch a l lenge d d u r i n g the range o f m o v e m e nt . I t represents a res t riction o f muscular fu ncli o n a n d t h e p a i n will appear whenever the c o n tract i l e e l e m e n t i s ca l l ed u p o n
t o move ei t he r
i n an
active o r resisted way, or w h e n the t iss u e i s
stre tche d . This will produce p a i n d u ring m o v e m e nt , a s w e l l as pa i n a t end-range The pain should ce ase o nce t h e c o n trac t io n , stre tch o r comp ression 1 S avoided . P a i n fro m this c a u s e w i l l n o t a p p e a r i f the p a t i e n t a voids the p a i n fu l or l i m i t e cl m o v e m e n t . S t re t c h i n g o r c o m p ress i o n of i mpe rfe c t fib rous repa i r i s the most c o m m o n cause of p e rs i s t i n g m usc u ! o tendoJ1O Lls, d i s c o m fo rt and pai n i n the ext re m i t i es .
Deran gement I n termi t t e n t mechanical pain may be du e to deforma t i o n of a rt i c u l a r s t ruct u res by inte rnal dera ngemenl. Ca rtilage fragm e n t s , o t h e r 'J oint d e b ris' o r menisca l t issues may b e i n t e rposed be tween J o i n t s u r faces cau sing b l ockage of moveme nt and abnormal s t re sses on pe ri -a rtic u l a r s t ructu res . I n a d verte n t 'mani p ulation' b y the p a t i e n t may re d uce t h e
par t ic le into l h e j oi n t recesses , a n d s o i l n o longe r co nst i t u t e s a blockage to movement or c a u s e of pai n . Cy r i a x ( 1 9 8 2 ) s t a le d t h a t such i n t e r n a l d e r a nge m e n t o f j o i n t s i s ' fa r co m m one r t h an w a s fo r m e r l y sup p osed' , e s p e c i a l l y a t t he k n e e , e l b o w, w r i s t , h i p , a c ro m i o c l a v i cu l a r and t e m p e ra - m a n d i b u l a r J o i n ts . A d e g ree 0 1' degenera t i o n or t ra u m a , which allows the p ro d u c t i o n o f t h e loose
body, is a necessary p re r e q u is i te for the co n d i ti o n . Examples incl u d e osteoch o n d ritis disseca ns at the knee o r e l bow, in
w hich re pea t e d micro - trau ma p ro d uces a p a tch o f necroti c bon e
resulting
i n i nt r a-a r t icul a r loose
bodi e s . These can ca use l o cki n g o f
the j O i n t , a b lockage t o fl e x ion o r e x tens io n , a n d may b e v i s i b l e using
magn etic radiographic imaging (Ho 1 99 5 ; Pallen 1 9 9 5 ) At the hip j oi n t , tears of the acetab u l a r labrum m a y p ro v o k e discrete e p 1s o d e s o f shar p pain when twisting, sometimes associ ated w ith a cl ick a s t h e loose t iss ue i s tra p ped in the j oint . Th e c o n d i tion may p rogress s o t h a t pain is fel t m o re frequently or even becomes co nsta n t . The onse t o f symptoms in t h e maj ority o f p a t ie n ts was assoc iated w i th m i no r inj u ries or n o trauma a t all ( F i t z ge ral d 1 9 9 5 )
PAI N
C H ArTE R
Mu l l i g a n
( 1 992)
h a s s u gg e s t e d m ob i l i s at i o n w i t h m o v e m e n t
te c h n i q u es f o r s u c h con d i tions as 'tennis e l b ow' a n d late ral li gament o f the a n k l e sp rain s The p roblems are said t o res o l ve ra p i d l y, unl ike true ten n is e l b ow. He p roposes minor articu lar p ositi onal fau lts ror s u c h pse u d o - t e n nis e l b ows a n d liga m e n t sprain s , p ossibly akin to de ra n gements . Twi nges and e p isodes o f pain a re l i k ely to be associ ated with blo c kage of m o v e ment as i n t h e examples above T h e c i rcu mstances wh e n the p a t i e n t I S p a i rdree may o ffer c l ues to trea tme n t st rategies . Some times t h e pa tie n t i s e v e n aware of certa i n m ovements th at m a nipu l a te t h e '
'
J o i n t s u fli c i e n t l y t o tem p o rari l y c l e a r t h e p a i nfu l ob s t ru c llon . A l t h o u g h t h e p a t i e n t w i t h inte r m i ttent signs o f d e r a n ge m e n t is c e rt a i n l y eas i e r t o
t re a t than
a
p a ti e nt w i th co n sta n t m e c h anical
d e range m e n t , t h is cond i t ion is m ore like ly to rec u r.
Chronic pain states The acu te a n d s u b - acu te mod e l of tiss ue i n j u ry a n d healing d esc r i b e d earlier is n o t a n approp riate mod e l for an u n d e rstanding of c h ronic
p a i n H p a i n p e r s i sts beyond t h e n o rmal healmg time , othe r fac t o rs may e x i s t w h i c h com p l i c a te t he p ictu re
U o h nson 1 9 9 7)
Persi s t e nt
p e r i p he ra l n o c i c e p t i ve input c an i n d u ce c h an ge s in the c e ntral n e rvous sys t e m (Wool f 1 99 1 ; M e l zack 1 988) . T h i s may lead to the se n s i t i saLi o n of n e u r o n e s i n the d o rs a l h o rn - a s tate charac terised by re d u c e d t h res hol d s and in creased res p o nses to arfe rent inpu t , such tha t norma l me ch a n i c a l sti mu l i i s i n t e rp re t e d as pain . As we l l , th e re
ma y be h e i g h t e n e d responses t o
r e p e ated
stim u l i , e x p an s i o n of
rece p t o r fie lds and s p o n t a neo u s ge n e ra t i o n o f n e u ronal activ i t y (Johnson
1 9 9 4)
1 9 9 7 ; Sid d a l l
an d C o u s i ns
1997;
Dubner
199 1 ;
Cou sins
This i s known as c e n t ral sensitisation . Thus , nocice p t ive S igna ls
c a n a lso b e i n itiated in a ltere d p a r t s of the peripheral or cent ral ne rvous sys t e m which may p roduce the e ffe c t of loca l ised pha n t o m '
'
pain i n a pan o f the p e r i phe r y w here tissue damage no l o n ge r exists (Bogd u k 1 99 3 ; Zi mmermann
1 9 89)
Pai n may radiate into uninj ure d
areas ad j a c e nt to t h e original p roblem
( sec o n d a ry
hyperalge s i a ) ,
n o rm a l movement c a n be p a i n fu l (all o d y n i a ) , repe a t e d m ovem e n ts can e xagge rate p ain res ponses , and pa i n sign a ls
m ay
fire o ff w i thou t
a n y a p p ropriate s t i mulus (ecto pic p a i n S ignals) . PsychOS O C i a l fac L ors ce r t ai n l y have a role in p e oples' resp o nse t o a pa i n fu l expe rience a n d may also be i m p o r tant in maintaining c hron ic
TH REE
\ 75
76 1 C H A PT E R T H RE E
TH E
H U M A N E XT R E M I T I E S : M E C H A N I C A L D I A G N O S I S & T I IE R A I ' Y
pain (Bogd u k 1993 J o hnso n
1 9 9 7) Factors a ffe ct ing pain
responses
a re cultural , le ar n e d behaviour, m eaning o f p a i n , fear a n d a n x i e t y,
n e uro t icism , lack of control of e v en t s , pass i v e co p i ng s t yl e a n d foc u s o n t h e pain (Cousins a t all stag e s o f
a
1 9 94) . Cl i nicians' b ehavIOur
t o wards patie nts
con dition shou ld gu ard a g a i n s t e n c oura gi ng a n y of
these p a ssive responses t o pain - e s p e C i al l y in the c h r o n ic p atie nt. It
is hardly su rp rising t ha t p a t ien t s ge t d e p re ss e d , anxiou s , fear fu l a n d foc u s ed o n t h e i r p e r si s t e n t pain. Heal th ca re p r o fe SS i o n a l s s e e m u n a b le to d e a l with i t , s o me o f w h o m i m ply i t is prima r i l y 'in t he i r
heads' as t he p a i n is ' a p p a ren t ly d i s c o rd a n t w i t h d i s c er n i b l e a b n o rm a l i t i e s ' ( Aw e r b u c h 1 9 9 5 )
Malada pt ive o r ina p pro p riate
b e h a v i o u r i n th e face o f ongoin g pain , h ow e v e r, d oes not rep resen t m a l i nge r i n g . I t s h o u l d be re m e mbered t h a t o n t h e w h ole t h e
emotional d isturbance is m o re l i ke l y to be a co n s e q uen ce o f chronic p a i n , rather than its cause (Gamsa 1 9 90) There are th us ne u rophysio l o gical and psycho logica l reasons L h a t a re ca pable o f main taining p a infu l s t a te s beyond the n o rma l t i m e s c a l e (Meyer e t
a1. 1 9 9 4 ; Co usins 1 9 94) The patie n t with a ch roni c
co n di t i o n may be n o t only e xp e ri e n c i ng persiste nt pain , but a lso be d istre sse d , i nactive, de co n d i t i o ned , have unhe l p fu l beli e fs about pa in , be overly p a ssi v e a n d re lian L o n o thers , a n d pO SS i b l y suffe r i n g eco n o m i c a n d soc ial deprivations d u e t o the i m p a c t o f t h e condi t i o n o n t heir li fes t y le ( N icholas 1 9 9 6) . T h e prevalence o f t h is chro n i c
pain syn d ro me is u n known ; it is poss i b l y a factor
in
those w h o se
pain has persisted for m o n t h s or y e a rs U o h n son 1 9 9 7 ) Such
a
sta te
m a y c l o u d the d i a gn o s tic and thera peu t ic u s e fu l ness o f mec han ica l ly
pro d u ced sy m p tom responses (Zusman 1 994) . The refore i n s o me patients wi th chronic pain co ndi t i o ns there exist va r i o us fac t o rs wh ich may confo u n d a t tempts t o r es o l v e the p ro b l e m , a nd w h i ch may
confuse d i a gn o sis a n d sy m p t o m respons e . Gi ffo rd ( 1 9 98)
0 f re rs a u se fu l
ap proach t o Lh is sm all but d i [ficu l t
p a t i en t gro u p . " O n -going pain states a re best exp l a i ned t o pa t i e n ts i n
terms oj a n a l te red s e ns i t i v i ty s ta te a s a re s u l t oj a l t e red
i nJo rmation
p ro c ess i ng t h roughout t h e sy s te m , a n d n o t sole ly a res u l i oj damage d a n d degene rat ing tissues . Th i s h e lps pat i e n ts ac c e p t t h e n o t ion t h a t hu rt does not n e c e s s a ri ly e q uate w i t h h a r m - w h i ch leads o n t o t h e pos i t i v e message that c areJu l ly g raded i n c re a s e s in phys i c a l a c t i v i ty m ean s t ro nge r and healthi e r t i s s ues . By con t rast, c o n t i l1 11ed Joc us 0 11 a t i s s ue as the pain source re i nJo rc e s Je a r oj m.ovement and ac t i v i ty, the need to be c on s ta nt ly v i g i lan t Jor pain and t h e des i re Jor i n creas ingly
PA I N
C H A I 'T E R T H R E E
expensive pass i v e t h e rape u t i c i n te rven t i o ns that are yet to demon s t rate con v i n c i n g effi ca cy " (p 33) A l t h o u g h t he s e c o m p l i ca t i ng fa c t o rs may u n d e rm i n e t r e a t m e n t a t lempts , many p a t i e n ts \;vi t h p e rsistent sym p to m s w i l l resp o nd t o m e c h a n i ca l the ra py, a n d a mecha n i cal assessme n t sho u l d never b e d e n i e d p a t i e n t s a c c o r d i n g t o th e d u r a t i o n o f t he i r s y m p t o m s .
H o w e v e r, i n p a t ie n t s w i th p e rs i s t e n t sym p toms there is a n e e d to re cognise the poss i b l e i m portance o f non- mechanical p a i n behavi o u r. T h i s may involve p e ri p h e r a l s e n s i t i s a t i o n , c e n t ra l sensi t i s a t ion o r psyc hosoc i a l ly me d i a ted p a i n behavi o u r, o r any combination o f these fa ctors , w h ich w i l l obs c u re or com pli c a te any p u re l y m e c h an i c a l a p p roach . T h e causes o r c h ro n i c p a i n a re d i ffere n t from the c a u s e s o r a c u t.e pa i n A l t h o u g h b o t h p ro b lems may e n c o u rage re d u c e d n o rmal use of tne n u rt i ng part, i n t h e a c u t e s tage this is ap p ropriate and re l e v a n t , w h e re a s in t he c h ro n i c s t a ge this i s inap p ro p r i a t e a n d
irrele va n t T h u s the mana ge m e n t o f t h e s e two stages o f a c o n d i t i o n s h ou l d lo g i c a l l y be d r ive n by a d i ffe re n t a p p ro a c h .
Co n c l u s i o n
-
the state of the t i s s ues
W h e n p a t ie n t s p re s e nt wi t h p a i n ful m u sc u l oske l e t a l p ro blems this
m a y t h u s b e d u e t o d i ffe re n t cond i t i ons in peripheral o r centra l s t ru c t ur e s . Tissu es m a y be in o n e o f five a b n o rma l s t a t e s , wi t h t h e
pain m a i nt a i n e d by d i ff e re n t mechanisms Tab l e 3 . 1 State
The state
of
the tissues
of L i s s u e s
P a i n m ec h a n i s m
norma l
( a b n orma l
i n f1 a m e d ne a l i n g
(ac u t e )
pred o m i n a n t l y
(sub-acute)
a b n o r m a l ( c o n t ra c l e cl/s c a r
stress
-
mecha n i ca l)
c n emical
c he m i c a l/m e c na n ic a l i n t e rface
t issue)
m e c h a n ica l
a b n o r ma l ( d e ra n ge m e n t)
m ec n a n i c a l
p e r s l s l i n g h y p e rse n s i l i v l t y ( c h ro n i c)
peri p he raVc e n t ra l
sens i t isation
F ro m t n e h is t o r y - t a k i ng a n d p hYSic a l e x a m i na t ion we n e e d to be a b l e t o d i s t i nguish be t w e e n these d i fferent states so th a t t h e d i ffe re n t and a p p ro p ri a te m a n age m e n t s t ra tegies can be i n trod u ce d .
177
78 1 C H A P T E R T H RE E
T H E H U MA N EXTRE M I T I ES: M EC H AN I CAL D I AG N O S I S & TH E RA PY
CHAPTER FOUR
4: Mechanical Diagnosis
Introduction Clinicians and p a tien ts like to have a diagnosis. The medical model is founded on the principle 01 a diagnosis pre ce d ing treatment. Indeed, it is necessary to have a precise diagnosis if one is about to commit a p a t ient to any invasive therapeutic proced u re. However, a tissue-specific diagnosis is not a prerequisite for the delivery of non
in vas ive therapies such as those provided by physiotheraplsts. While it is true that it is more sat isfying professlOnal1y to have made a specific
diagnos i s for p hysiotherapis ts the abse nce of a d iagnosis need not ,
impair the treatment process itself. The medical model Clinicians within different spe c ialities require different levels of diagn ostic precision. A surgeon about to perform a tendon transplant or repair must know p re ci sel y what is wrong with the affected structures. The exact location of the d amage must be identified. There needs to be a precise correlation between the pathoanatomy and the s ource 01 the patient's symptoms It must be clear what is to be done
to modify and repair the anatomical disruption The surge on must therefore have a precise diagnosis, and the experience and expert ise
to perform the procedure and achieve a successful outcome. Without
tha t diagnosis and expertise, surgery is hazardous and further injury inevitable.
The same pre c i sion in d ia gnosis is required, for example when ,
injections are contemplated for the t reatm e nt of tendonitis or capsulit is of the sh ou lder. The affected structure must be accurately
identilied Precis ion in del ivery is vital for the success of the procedure
.
The role of diagnosis in musculoskeletal problems It has been customary [or clinicians to attempt to obtain a precise diagnOS iS when assessing muscul os kele tal disorders. Traditionally,
the affected
an
a t o mical structure is first identified. Then it is
determined w hat t he problem with that structu re might be. This
information allows the implementation of the treatment protocol
179
I
80 CHAPTER FOUR
THE HUMAN EXTREMITIES: MECHANICAL DIAGNOSIS & THEMI'Y
usually recommended lor such a problem
Identification of the
affected structure is achieved by follOWing a recommended sequence of active, resisted and end-range movements. James Cyriax
(1982)
developed his system of selective tissue Lension testing which aLLempLs the specific identification of sources of musculoskeletal pain This testing is an attempt to identify the precise 10caLion of lesions requiring either injection or frictional massage. Using this system iL may be possible to locate the structure at fault. As was noted in the Introductory chapter, problems exist concerning the value of this structural diagnosis. First, there is no absolute evidence that tests, which purport to examine certain strucLures, actually do so - the problem of validity Second, the evidence demonstrates that different clinicians will frequently come to di fbenL conclusions when using these tests - the problem of reliability (Liesdek ct al.
1997; Cushnaghan
ct
al. 1990) Within this area it
has been shown that symptomatic responses can be assessed more reliably than physical signs Oones ct al.
1992).
Third, it might be quesLioned if it is reall y necessary for the clinician to obtain a specific diagnosis when invasive therapy is not uncler consideration. The answer might be 'no', as long as Lhere is a general understanding of musculoskeletal tissue beh8viour in health and pathology and the implications this has on management
What
difference will a diagnostic label of structural pathology make to the treatment process7lf the clinician is unable to reach a finn diagnosis because signs and symptoms are confusing or contradiclory, does this mean they are incapable of offering a management strategy? Furthermore, a tissue-specific diagnosis, even if readily obtainable, will not reveal the stage of a disorder which will determine the vigour with which to commence thera p eutic activity and is a crucial determinant of management decisions. Whether
a
condition is acute
or chronic is often more relevant to this decision than a precise diagnosis. A diagnosis that implicates a certain tissue also cannot determine what type of pain is present - whether Lhe source is local nociceptive, central sensitisation or relaLed Lo higher centres. Whatever the diagnosis actually is, the clinician vvill assess the patients response to certain movements and then manage the patient in light of the responses obtained. In many cases knowing which structure is the cause of the pain appears to be purely academic and is not
MFCHANICAL DIAGNOSIS
C HA I'TE R
necessary lor treatment to occur. Management of the patie n t may continue in the absence 01 a specific structural diagnosis, but will be based upon the patient's responses to treatment as reOected in changes in symptoms, movement and [unction. Within physiotherapy,
management is often determined by a patient's lmpaim1ent, disability
and the stage 01 the d isorder; that is, a general rather than a specific tissue diagnosis Uette and Delitto 1997; van Baar et al. 1998; Dekker et
al. 1993)
Making a non-specific diagnosis The problems of diagnosis I-or non-specific mechanical disorders of
the spine are well documented (Spitzer et aI. 1987; Rosen
et
al. 1994)
In order to overcome those difficulties, an alternative system of classifying spinal d isorders was proposed by McKenzie (1981). This system is based on t he symptomatic and mechanical responses of patients to various repeated movements or static loading forces (that is, a mechanical evaluation). [r allows the classification of patie n ts into broad rather t h a n tissue-specific categories, and thus leads to the Cormulation or treatment. Rather than se e king to make a diagnosis, which is the id entification of a disease by means of its signs and symptoms, the McKenzie system concentrates on sy n d rome identification A syndrome is a group of symptoms and a pattern of responses characteristic or a particular p ro ble m The system is now .
widely used to claSSify and treat patients with mechanical sp i nal disorders McKenzie (1981) suggested that this method of assessment was equally applicable and effective fo r the assessment and treatment of mechanical musculoskeletal disorders of the human extremities. By applying
a
structured sequence of loading forces, it is possible to
identify three separate mechanical syndromes. The characteristics of each s)rndrome in response to repeated and/or sustained end-range loading are completely dilTerent from each other. Within these s y nd rome s can be found the vast majority of mechanical disorders of the musculoskeletal system The history taki ng and examination -
described in later chapters therefore needs to determine the stage of
the disorder and the response to mechanical load ing. This assessment should allow classification into one of the following mechanical syndromes an inflammatory problem following injury or a chronic pain syndrome.
Fou R
181
821 CHAPTER
FOUR
THE HUMAN
EXTREMITIES: MECHANICAL DIAGNOSIS & TllERAI'Y
The postural syndrome Pain from the postu ral syndrome is caused by mechanical deformaLion of soft tis sues or vascular d e p r iv at i o n arising from prol on ge d positional or postural stresses a ffe ctin g the arti cu l a r structures or the contractile muscles, their ten do n s or the periosteal insertions. When postura l pain arises from joint c a psu le s or a dj ac en t supportive ligaments, it is the result of prolonged end-range positioning Moving [rom the en d range is SUffiClenL to relieve pain immediately -
When postural pain arises from contractile tissues
it is usua lly
the
resull of prolonge d s ta L ic mi d range l oad ing. A lthough the Joint may -
be in mi d ran ge , th1S will not re n e er the state of the cOnLractile t iss u e s -
that are hol di ng the Joint in that position. This may ca use mechanical
deformation of tissues or a re d u cti on in blood supply, so th a t there is a build-up of metabolites and rela t i ve
ischaemia. Relief from pa in
can be obtained with a cha n ge of position that allows sufficient relaxation of the involved musculature. This removes tension from
the cont r ac t ile tissue and permits the return of normal vascularity Thus, the postural syndrome is
c h a racterise d
by inLermittent pain
brough t on only by pro l on ged static loading of normal tissues. Patienls
with the p os tu ra l syndrome experience no pain with movemenL or activity, nor do they su ffe r restriction of movement. No pathological
changes occur in this syndrome. Clinically, pa ti e nts with p a in of pos t u ra l s yndro me are not oflen seen. However, the role of postural stresses on the ge ne sis and persistence of mu s c u l os ke leta l conditions is very important. Poslural sy n d rom e is not a discrete entity, but a part of a continuum These palients, if they do not alter their static and dynamic pos tural habits, can progress to cumulative trauma disorders or re p etit i ve strain injuries Dynamic postural stresses also have a role in prolonging a varie ty of disorders, for instance anterior kn ee pain and late ra l epi co n d yli t i s.
The dysfunction syndrome Pain from the dysfunct ion s y n d ro m e is caused by mechanical deformation o f structurally impaired soft tissues. This abnormallissue may be t h e p ro d u ct of previous t r au m a or inflammatory or degenerative processes These events cause conlraction, scarring, adherence or adaptive shortening. Pain is Felt when the abnormal tissue is loaded.
MECH/\NICAL DIAGNOSIS
When structural cha nge s and or im p ai rmen t affect joint cap su l es or adjacent supporting ligaments, painful res t ric ti on of end- ran ge movements in one or mo r e directions will be experienced When structural cha nges and or impairment affect con trac t ile muscles or te n do n s , pain may be experienced during re sisted movement or loading at any poi nt thro u gh the whole range Pain on resisted movement will usu all y occur in one direction, and pain will also be provoked if the Lissue can be stret c he d . In other words, the d ys f u n ction will i m pair both types of movement that are required in the no r mal activity of a muscle - both as it contracts and as it is stretched. III the d y s funct io n syndrome , pain is never constant and appears
only as the affected str uctu res are mechanically loaded. Pain will stop almost immedIately on cessation o f loadi n g . Thus, when a ffec t ing articular structures, the d y sfun cti on syndrome is al w a y s characterised by intermittent pain anel a res triction of enel
ran ge movement. Whe n affecting the contractile elements, the d y sfun c t ion syndrome is characterised by i n te rmi ttent pain occurring only eluring movemenL or loading of the structural impairmen t . This may be mid- range for the J oi n t , but end-range for the contra c tile Lissue.
Pain Crom the d ys functi o n sy ndro me will persist until remodelling of the affected structures has occurred. In dysCunction involving peri a rt icular structures, this will be a t tained once the range of motion has returned to normal. In co n trac t ile structures the remodelling process must affect the tissues' ability to contract as well as to be stretched
This can take months, and in some cases pain persists
throughout life P atien t s with dys fun ctio n sy n d rom e in pe ri phera l tissues are very c o mmo n ly seen in the clinic
The derangement syndrome Pain from t he derangement sy n d ro m e , when affec ti n g the spi nal column, is caused by internal dis rup t io n anel d is p lac eme nt of the
flui d nucleus/annulus com plex of the intervertebral disc . This in turn mechanically d efo rm s the ollLer innervated an n ulus fibroses and/or adpcen t soft tissues resu lt ing in back pain alone or back and referred pain de p end mg on the degree of internal displacement and w hethe r or not this causes compression of the n e r v e root. The pain of
CHAPTER FOUR
183
841 CHAPTER
FOUR
THE HUr'vlAN EXTREMITIES: MECHANICAl DIAGNOSIS & THERMY
derangement is often constant and remains constant until the displaced tissue is reduced. As a result of displacement of tissue within the intact annulus, sudden obstruction to movement can occur at the time of the onset of pain Repeated movements that increase the displacement also increase the obsLruction thaL in turn increases the pain. Repeated movements Lhat progressively reduce the pain also progressively reduce the obstruction and derangemem and allow the restoration of normal pain-free movement. Cyriax
(1982) believed Lhat internal derangemenL o[ Joims is a
common cause of many obscure pains in the extremities. \Vhen affecting the knee and other articulations containing meniscoid cartilage, tearing and or displacement of the deranged menisci can similarly cause painful locking and lor sudden obstrucllon to movement. Almost any articulation has the potential to develop loose bodies that can displace ancl cause similar symptoms Joints most affected are the knee, wrist, elbow, acromioclavicular and ankle, hip and tempero-mandibular Certain repeate d movements that progreSSively reduce the pain also have the capacity to reduce the obstruction or locking Internal derangement may cause a disturbance in the normal resting position of the affected joint surfaces. This will, in turn, deform the capsule and peri-articular supportive ligaments resulting in pain. Internal dislocation of articular tissue of whatever origin will cause pain to remain constant until such time as the
displacement is reduced or adaptive changes have remodelled the displaced tissues. Internal dislocation of articular tissue obstructs movement attempted towards the direction of displacement. The derangement syndrome is often characterised by constant pain Intermittem pain may be described when the size or the displacemem is smaller and when the patient's movements or positions during the day are able to reduce the derangement so that it lS no longer causing symptoms Movements that open the Joirll space n1ay temporarily reduce the pain, but promote greater displacement and more pain when the limb is moved again Thus certain positions can be found that alleviate the pain while the position is maintained, but which aggravate or perpetuate the pain al·tenvards. Derangement requires movement that encourages reduction or displaced articular tissue This process can often be achieved rapidly
MECHANICAL DIAGNOSIS
CHArTER FOUR
Days rather than weeks of exercise are required [or the completion of the reduction process. In some cases, particularly when the wrist and elbow are involved, immediate reduction can be achieved in a few minutes.
Non-mechanical conditions So far musculoskeletal conditions that behave in a straightforward mechanical manner have been described. Mechanical loading or deformatio n produces pain either immediately or after sustained loadtng in all three syndromes, and cessation o[ that tissue loading or deformation c a us e s the pain to abate. In certain instances, although mechanical I-actors may be significant in pain behaviour, other [actors must also be considered. These are the acute and chronic phases of musculoskeletal conditions
Acute pain Immediat ely following t rauma or the insidious onset of
a
musculoskeletal condition, the prime pain generator is likely to be chemical. Although mechanical forces will aggravate the symptoms, they cannot be usecl to relieve them when the pain is primarily inflammatory in nature. However, the period when rest and relative rest are appropriate is short-lived - less than a week following an
injury If prolonged, this strategy will start to have a deleterious effect on recovery and function. During the sub-acute phase, tissue strength is low and re-inJury is possible
if functional rehabilitation is progressed
too rapidly
Chronic pain Very often even symptoms that have persisted for months or years can behave Il1 a mechanical fashion and can be easily classified into one of the mechanical syndromes outlined above. The persistence of a
proble m must never be used as the sole determinant of suitability
[or mechanical diagnosis and therapy However, as has been discussed in Chapter Three, various non-mechanical factors may complicate
interpretation of pain behaviour in chronic pain stales.
The mos t relevant issue is the sensitisation of tissues that may occur peripherally and centrally in chronic pain. This will exaggerate responses to mechanical loading, producing pain when loading is absent, pOSSibly causing constant symptoms and perpetuating maladaptive pain behaviour. Clinically this may loo k like chronic
IS5
861 CHAPTER
FOUR
THE HUMAN EXTREMITIES: MECHANICAL DIAGNOSIS &THERAI'Y
inflammation, but rather than inflammatory chemicals mediating the pain this is largely the product of sensitised, d econ d it i o ne d and abnormal tissue. This needs progressive functional loadi n g to Lry to rectify the problem, and an initial mild aggravation. of symptoms may occur. The exaggerated responses to mechanical loading that may be found in chronic conditions obscures and confuses normal mechanical responses. Once a prog ress i ve functional rehabilitation pr o gramme has been started and the patient is repeatedly loading those tissues, an underlying
r e gu
m ec
l arl y and
h ani c al pain
behaviour can sometimes be revealed. It is, at times, as if regular exercise therapy is a ble to desensitise the tissues so that normal mechanical responses are seen.
Conclusion The three mechanical sy n dro mes presented describe com pletely di [ferent patterns of mechanical and symptomatic responses when subjected to a structured repeated end-range movement and static loadin g evaluation. Each syndrome resp onse to repeated movements is different from the other syndromes, and each syndrome must be treated as an entity on its o\Nn . Different information needs to be given to patients with the different syndromes, and they need to be instru cte d in di fferent exercise procedures with different symptomatic r e spons e s Patients in the acute phase of a problem have pain that is primarily mediated by inflammatory cells and so their management is different Many patients with chronic conditions will respond in a normal mechanical way However, in some cases e xagge ra t ed sensitivity will persist long after the acute phase and deter the patient from normal activity Various behavioural factors may have
a
role in symptom
prolon gat i on such as fear-avoidance behaviour, p oo r seU·-efficacy or passive coping strategies Patients need to be encouraged through the initial aggravation of symptoms that is likely to occur u p on starting a programme of p rog reSS i ve functional restoration
-
an
underlying
mechanical response to tissue loading may be found. Instances where there have been major neurophYSiological or behavioural changes may need a multi-diSCiplinary approach Ra tes of failure to respond will be high in this group
.
MECHANICAL DIAGNOSIS
In order to identify wh.ich. s ynd ro me is p resent in a particular patient, a history must be established and an examination must be performed. Following the syndrome identification, a p a tient management plan
must be devised. The method of history-taking, the mechanical evaluaLion and patient management plan are discussed in the following chapters.
CHAPTER FOUR
187
1
88 CHAPTER FOUR
THE HUMAN EXTREMITIES: MECHANICAL DIAGNOSIS & THERAPY
CHArTER
5: History
Introduction "Every patient contains
a truth...
The [clinician] must adopt a
conscious humility, not towards the patient, but towards the truth co n c e a l e d within the patient" (Cyriax 1982 45) The pa tient knows the details of the history, onse t, symptom pa t tern and behaviour since onset, and aggravati ng and re lieving factors. This information is vital to gain knowledge of the disorder. In order to ac cess this truth, the clinician must approach the patie nt in a respectful and friendly way, they must have a logical forma t for collecting informa tio n and , most imponanLiy, they mus t listen actively to the patien t's responses. Only from the patient is it possible to gain insights i nto various aspe c ts of the clinical present ation, which are essential to inform issues such as
the stage and nature of the dls o r d e r, the pro gno sis and the management. Very often taking a history will provide information that is at le a st as Important as tha t gained from the physic a l examina tion, i f not more so. One of the key aspec t s of an episode of health care that a ffe cts patient satisfaction is the relationship between the patient and the clinician.
Of partic u lar i mport a nce are c ommunic a tion, empa thy a nd re assurance ( Si(zia and Wood 1997; We nsing et al. 1994)
It is
important tha t we make the pa t ient as comfortable and as relaxed as is possible
Pat ients will enter all clinical situa tions with the ir own
expecta tions, fe elings and fears (Brown et al. 1986). It is important that these issues are recognised by the clinician, fears are allayed a n d questions answered. 1 t i s important to avoid t h e u s e o f medical words or phrases that may be foreign to the patient. Conversation should be conducted using terms and phrases with which the patie n t will feel comfortable. From the outset listening is a key skill to clinicians, without whi c h the i nforma tion tha t the patien t can provide will be useless - the clinician's understanding of their condition will be limited and the ir management will not be optimal. Another aspect of care which is impor t a n t in terms of the patient'S sa tisfac t ion is profeSS i onal skills. These may be displayed by clinician's thoroughness, a ccuracy of assessment and understanding of the patient'S problem (Sitzia and Wood 1997; Wensing et al. 1994) An
FIVEIS9
901 CHAPTER
FIVE
THE
HUMAN EXTRHvlITIES: MECHANICAL DIAGNOSIS &
THERAPY
initial way to d isplay these skills is the use of a structured but flexible interview format so that all pertinent factors from the hisLo ry and
behaviour of the c o n d i t i o n are collected. The standard assessment form includes the most i mportam aspe c ts
of the history that need ga th ering; mos tly it will be unnecessary to a dd to this information. Be wary of gathering excessive amounts of
information - a l ways c onsider 'how will the answer help in managing thiS pa t ie n t !' If it is deem e d essential to gather further details about a p art i c ular aspect of the clinical p re se n ta L io n that causes concern, the form should not pr eve n t further specific ques tioning. It IS best to
gather the informa tion u sing open-ended quesLions first so tha t patients may volunteer the i r own answers rather than u si n g leading
questions. Focused questions may be used to follow up if particular as p ects need more detailed i n fo rmation Thus, management decisions can be grounded in the particu lar patient's problem and their response to it.
Aims of history-taking Using the form and the appropr iate ques tioning technique after taking the history, ideally the following will h ave been obtained an overall impression of the c l i ni c a l
presentation
the stage of the disorder - acute / sub-acute / chronic
the status of the condi tion - improving / unchanging / worsening a hypothetica l diagnosis b y syndrome and site of lesion baseline measurements of the sy m p t o m a t i c (and mechanical
presentations) a g a i n s t which improvements can be Judged factors tha t aggravate and relieve the problem, which may help guide fu ture management the severity of t he p r oblem which may gui de the intensity of the physical examination the functional limitatio ns tha t the c o nd i tion has imposed on the p a tient's qua li ty of life an impression about the way the p a t ie nt is responding to their c ondition, and how much e n c o u r a g e m e n t , informa tion,
reassurance Of c onv i n c i n g they ma y ne e d to be a c tive participants in the if own management.
CHAPTER
HISTORY
The interview Age We need to be aware of the patient s age. Certain disorders are '
associated with particular ages. Degenerative and overuse problems start lO become more frequent in thos e over 40. Frozen shoulder is
rare in those younger than this, except in those who have had trauma, but after th i S age IS not unusual as a problem which starts withou t known cause. Anterior knee pain not due to patellar-femoral
osteoarthritis is most common in the young
-
teenage girls and you ng
men in their twenties are commonly bothered by this complaint.
The age of the patient may also be significant in their response to the problem. Increasing years not only raise the susceptibility to disease and injury , but also reduce the body's ability to recover from the effects of musculoskeletal disease and injury (Buckwalter et al.
1993)
A patient's age is therefore importa nt in their prognosis
Work and leisure activities Particular employment may be significant in the aetiology and persistence of the patient's problem. Find out wha t their job is and about the postures and stresses t hat it involves. Carpet l a yers and -
those forced to kneel a lot of the time may develop knee problems
-
protective measures such as knee pads may be i mp ortant in
management. Those involved in clerical work,
in activities with
repetitive arm activities suc h as worki ng on a conveyor belt, or in tasks that involve using the arms abov e the head may all be prone to developing overuse tendonitis problems of the arm. Relative rest, analysis of t hei r activity and frequent interruption of the task may be an important pan of management. A worker's inability to interrupt the activity may be signi ficant in a poor prognostic outlook. Equally, certain leisure activities may be important in the genesis of a problem, and the p a tient s normalleve1 of sports and hobbies should '
always be discussed. This will also give an i dea about the patient's
general level of exercise or lack of it. If patients have sto pped certain a ctiv ities it is important to know
if th is is because it actually makes
the pain worse or because they think it will make the pain worse. Functional disability Find oUl what li mi tations in normal activity the present episode has caused Il is importan t to know if the patient is on sick leave or has curtailed his or her usual leisure activities because of the problem
.
FIVEI91
921 CHAPTER
FIVE
THE HUMAN EXTREMITIES: MECHANICAL DIAGNOSIS & TI-IERArV
Long-term work absence due to musculoskeletal disorders is the cause of major expense throughout the developed world, and return to work is seen as a key goal of any intervention. Loss ol work can also cause the individual severe financial hardship, affect their societal and domestic roles and encourage inappropriate pain behaviours As
a
result, "a basic tenet oj secondary prevention [of chronic
musculoskeletal pain] is to intervene early to prevent the disruption oj the patient's normal liJestyle, including work" (Linton 1996) and to encourage an early return to normal activity, even if gradual. The patient's level of function pnor to the problem is the suitable goal for management, and so remodelling and rehabilitation exercises need to be targeted at the appropriate functional or spomng tasks for that individual. This has important Implications for management
Where is the present pain? Discuss the location of the pain during this episode
This gives a
general indication of the site or sites that need to be included in the physical examination. Find out where the pain was at onset and if there has been any change since then: for instance, the pain may have become more or less widespread since onset. IL can generally be smd that as the condition worsens the pain will become more Widespread and frequently win move distally. Conversely, as the condition improves iL is common to see diffuse symptoms contracL to a localised point close to the site of the initial injury It is not uncommon for shoulder, elbow, hip and knee problems, when at their worst, to refer symptoms dovvn the arm or leg respectively Only rarely are symptoms ever referred up the limb Ask if the pain is always located in the same place or if it changes location with movement or over time. If Lhe pain is more Widespread at the end of the day compared with the morning, it may be
an
indication that more rest is required or that aggravaLing factors are introduced during the day. Often the anatomical source of distal extremity problems is reasonably clear. However, confusion occurs espeCially if the pain
IS
located
proximally in the limb. The site of pain of many musculoskeletal problems can be quite separate from the source. Pain I-rom lhe hip can be felt entirely at the knee, articular shoulder problems are frequently felt at the top of the ann, isolated sympLoms in Lhe leg can remain unchanged until the spine is tested
ann or
Only eliminate
CHAPTER FIVE
HISTORY
the spi n e as a source of problems when peripheral tissue loadi ng clearly brings lasting c han ges to the patient s symptoms '
Problems at the shoulder or hip are especially easy to confuse with
spinal problems The specific area of pain is one way of helping to clari fy these ambiguities. Pain from the shoulde r is usually felt around the shoulder joint or at Lhe top of the arm, whereas pain thaL is felt around lhe scapular, posterior shoulder, or base of the neck is likely to be cervical in origin and necessi tates an examination of the cervical spine The occ urrence of neck and shoulder pain together is very common, both pro blems being concurrent in nearly half of a sample of over 300 pa tie nts (van de r Windt et al. 1995) The area of re ferred pain in the leg may help distinguish a hip from
a lumbar problem The sites of referred pain
in
89
patien ts with
osteoarthritis of the h ip were combinations of t he greater trochan te r
knee, an ter ior thigh, groin, shin and buttock (Wroblewski 1978)
,
In
patients who present with some combination of these pain sites,
especially if the pain is worsened on weight-bearing and eased by sitting, the
hip joint should
be suspected. However, in both putative
shoulder and hip p ro b lems it is always wise to e xc lude the spine first The presence of numbness, tingling , wasting or weakness should
be enq uire d aboUl, and H present should clearly shift the index of suspicion to lhe s pi ne
.
How long has the pain been present?
Knowing the lengt h of t ime that the problem has been present allows us to determine the S L a te of the tissues Days after onset tissues may .
be damaged and inOamed, whereas a few weeks later ti ssues may be healing If the symptoms have been present for a couple of months, adaptive shortening may have occurred in the collage nous repair tissue indicating Lhat d ys funct ion may be the cause of p e rsisting symptoms. If the prob le m has been present for many months, although
a
straightforward mechanical condition may be present,
the chance that the tissues
are hypersensitive and deconditioned
should be born in mind. Chronic pain syndromes often compl icate
the management of persistent pain and may, although no t al ways
,
make treatment less effective. Pam that has been present for many
months as well as having a poorer prognosis may respond more slowly when it cl oes respond. Many p atients have a long or recurrent history of their problem and therefore the edu c ationa l component of management is particularly important to improve their future self-
193
941 O-lMTER
FIVE
THE HUMAN EXTREMITIES: MECI-IANICAL DIAGNOSIS & THUtAPY
care. The duration of the e pi sode thus provides diagnostic and prognostic information. This should be classified as acute, su b acu te or chronic These terms -
tend to be interpreted slight ly differently by different auth ors ; thus there is a certain ambiguity an d arbitrariness about these divisions. For sake of clarity they will be defined here as follows acute - pain present for less than seven days sub-acute - pain prese nt from one week to se ven weeks chronic - pain present for more than seven weeks. The length of time that the patient has had symptoms can also guide us in deciding how vigorous we can be with mechanical assessment procedures If a patient has had symptoms for several months and has been able to work or remain active during this time, he or she
'vvil! probably have placed more stress on the structures at faull than we are likely to apply during our assessment p roces s This allows us to be fairl y intense with the overall mechanical assessment However, someone who presents with an injury of very re cent onset needs to be examined 'Arith more care and managed in a completely different
way If the symptoms have been of recent onset and are imp rovi ng it is ,
unlikely that any intervention other than ed u cat ion will be necessary
If the symptoms are of recent onset and are not imprO\ring, then it may be necessary for the
c
linici a n to encourage som e form of active
mechanical therapy
If the symptoms have been present for several weeks or months, education will always be helplul, but the longer the symptoms have been present the more likely it wi ll be that active mechanical the rapy will be required at an early stage in the management process. Did the pain commence following injury?
If the symptoms are of recent onset and have been caused by
injury,
an inflammatory sou rce of pain is l i k e ly and caution may be required in the physical examination. The exact mechanism of the injury should be determined if at all possible. The direction and force of the trauma may give clues as to the extent and nature of dama ge caused. Where significant trauma is i nvolve d it may well be that radiologlcal investigation is required. 'vVhen it is clear th at no fracture
H ISTOR.Y
or dislocation is present the extent of bruising or evidence of swelling should be determined. In any case, where patients have suffered recent trauma of any significance, the initial mechanical assessmem procedures should always be applied with caution. In acute cases the patient should be educated about the value of Rest, lee, Compression and Elevation Did the pain commence for no appare nt re ason?
A lternatively it should be asked if the symptoms came on for no apparent reason. Musculoskeletal complaints commonly start with no obvious trauma. For instance, a high proportion of cases or shoulder pain, lateral epicondylitis and anterior knee pain commence without any known precipitating cause (van der Windt et al. 1995; Binder and Hazleman 1983; Fulkerson and Shea 1990) Symptoms
of pain or limitation of movement commencing for no apparent reason are usually a result of inflammation, early degeneration, repetitive activity or prolonged positioning required within the domestic, recreational or occupational environment. We all experience environmental stresses of daily living. When patients complain of musculoskeleta l problems appearing for no apparent reason, the identIfication of the causative factors is important for successful management of the problem. Any of the foregoing causes could be responsible for any given problem and should be systematically sourced so that appropriate recommendations can be made regarding treatment and prevention of further unnecessary load ing. It is sOlnetimes impossible to discover a clear causative factor, but the high incidence of symptoms that appear for no apparent reason would suggest that environmental and degenerative factors play a key role
in the aetiology of musculoskeletal conditions. From the patient's history it may be possible to gain some inSight into the likely presence of a degenerative d isorder. If the older patient describes a slow insidious onset of stiffness and pain for no apparent reason, it is possible that degenerative problems affecting either the Joint or adjacent soft tissue are causative. The most common peripheral sites of degenerative changes are the knees, hands and feet, with hips, ankles and shoulders affected less frequently, and the elbows and wrists rarely (Petersson 1996; Huskisson and Hart 1987) Usually several sites become affected, and the majority describe stiffness in the morning and after inactivity It should be remembered that radiographic signs of degeneration are almost universal after 55,
C HAI)TER.
FIVE
195
961 CHArTER FIVE
THE HU,v\AN
EXTREMITIES:
MECHANICAL
DIAGNOSIS
&
TIIERAI'Y
but that symptoms are present in onl y about 50°/c) ot those wilh such changes (Huskisson and Hart
1987)
Onset of symptoms for no apparent reason may also result from environmental factors Everyday lifestyle a C livities can be, w i thoUl the patient being aware, the cause of many common musculoskeletal problems Certain sleeping postures may cause shoulder ann or hip
and leg symptoms Certain sitting postu res may also cause symptoms in the upper or lower limbs. The reJ ation ship between siltin g poslures and the onset of periphera l symptoms should be examined in detail as the origin of t he pain may well arise from the spine Sy mp t om s may also arise from repetitive loa d i ng incUlTed at work or during domestic or sporting activity. Sometimes patients have commenced a new occupati o n or a se den tary worker has become invol ved in more ph ysica l e mp loy m en t
,
and
symptoms develop because Ot unaccustomed activities. These activities on the surface may ap pe a r to (he pa t ient to be insufficient to cause their prob le m However, it the individual is not condiLioned .
(0 cope
with (he unaccustomed exertion, the relationship between
the new occupation or activity and the onset or symptoms should always be considered. Often patients are reluctant to accept that there is no obvious reason for the onset of symptoms and ascribe a causative role to some recent event. When questioned more closely it is apparent t haL the event, such as taking some unusual exercise or a fall, is a week removed from when the problem actually started. It is especially impor l a n t to disabuse patients of misconceived caus ali ty when il is apportioned to an attempt at exercise. Where symptoms have commenced for no apparent reason iL is always possible that some more sinister cause may be present The likelihood of the presence or otherwise of serioLls pathologies should be determined from further development of Lhe history and from the mechanical evaluation. Is the problem improving, worsening or unchanging ?
This important question determines the stage and status of the disorder, which will guide management decisions. Where the patient records that th e i r prob le m is steadily ITsolving it will be necessary to proVide only education at this point. Should improvement cease at
CHArTER FIVE
HISTORY
some l-uture point in time, the need for mechanical intervention can be considered then. In the event that the patient reports that their condllion is worsening,
measures must immediately be Laken to evaluate and identify the appropriate course of management. Certainly education must be provided on the f irs t day If the patient reports that their p ro blem is unchanging, education and possibly mechanical intervention may be required. Frequently patients report that after
an
initial period of improvement the
condition has been unchanged for several months, getting neither
better nor worse despite l i mitat ion of activities. Such a history suggests a need for a new more active approach to management, and a stable condition that \vill benefit from exercise. This type of history may begin to suggest the presence of persistent dysfunction, a chronic pain state, or a structure that has becOlTle 'stuck' in the healing process A
rairly vigorous management approach can be proposed in these
rela t ively stable conditions.
Is the pain constant? This is one or the most important questions with musculoskeletal disorders. Be sure that by 'constant pain' the patient does actually
mean that their pain is there '100 per cent of their waking day', 'from the moment you get up to the moment you fall asleep'. Some patients can always produce their pain with cerrain movements, and
they
interpret this as constancy Constant pain is caused by in fl amm ator y diseases and is also present
where patients have suffered recent trauma causing an inflammatory response. Constant pain may also result from internal articular
derangement. There will be various clues in the h is tory which \vill suggest which of these options are the most likely Mode of onset, age, ass o ci a te d stiffness and pain behaviour, for instance, will reveal
this. From the mechanical evaluation it will be possible to confirm whether
the cause is inflammatory or not. H the cause of the constant ache or pain is chemical the symptoms will not be reduced or abolished by mechanical assessment procedures. If the cause is
m
ec ha n i cal in
origin, movements and positions \vill usually be fou nd that reduce
or stop the aching or pain. Constant mechanical pain is the result of
197
981 CHAPTER.
FIVE
THE HUMAN EXTR.EMITIES: MECHANICAL DIAGNOSIS & THFRAI'Y
internal derangement The derangement syndrome can be asso cia ted .
with a constant ache, whereas patients with the p os tur al and dysfunction syndromes do not experien ce constant pain. Constant pain is more difficult to treat than intermittent pain because the patient is usually unable to identify a direct ional or postural preference. Chronic pain syndromes may also present with constant pain, which also may worsen initiall y on mechanical assessment. The history wi ll reveal the length of time symptoms have been present, and also may relate previous failed treatments. Constant pain may also be caused rarel y by serious non-musculoskeletal pathology Is the pain intermittent?
A description of intermittent pain generally excl udes the possibility that the pain is inflammatory. Should the pain cease at rest or when the pa tient is still, the pain is not a result of an inflammatory response and must therefore be mechanical in origin [t could be postural or result from dysfunction or derangement Intermittent pain is relatively easy to treat because if there is one hour in the day when no mechanical deformation is present, it is possible gradually to extend that pain free period by duplicating the -
favourable circumstances. In addition the patient is u su a l ly alread y ,
aware of certain movements or p O S iti ons that bring relief, thus indicati ng the likelihood of the presence of
a
di rectional or postural
preference.
A change in the fre q uency of the pain from constant to intermittent, or reduction of intermittent pain from being present most of the
time to present only so m e ti mes represents improvement in symptomatic presen tation Such improvement should help in the overall assessment of management s tra tegies lt is therefore useful to ask about the proportion of the day that pain is present This could be expressed as a percentage; for instance, "on average are your symptoms there for 80% of the day, 50% of the day, 20% or how much of the time/" What activities produce or worsen the pain? What activities stop or reduce the pain? Does it remain worse or better afterwards?
These questions allow the patient to provide the information that is
l i k e ly to lead to the appropriate man agemen t They are desi g ned to determine what movements or positions produce or abolish, or
CHAPTER FIVE 199
HISTORY
increase or decrease, mechanical loading and or deformation of the affected structures. ][ is important to record those movements, positions or activities that specifically reduce or relieve the pain as this information will be unlised in our management protocols. It is also important Lo record which movements or activities aggravate the symptoms As p art of the educational strategy it may be necessary to temporarily avoid such causative factors, or alter the wayan activity is performed so tnat stresses are lessened.
If symptoms are intermittent it is important to know the positions, movements or activities tnat produce the pain. We also ,vish to knmv if these activities consistently produce the pain, and what happens
when the activity is stopped. If pain is always b rought on by the same activity and ceases snortly after cessation of that activity, we may begin to suspect dysfunction. It is nelpl-ul to know if the movement that relieves or aggravates the
pain brings about
a lasting improvement or worsening
A lasting
improvement [ollowing a particular loading strategy will give a useful idea about self-treatment procedures. If pain is produced by certain activities but quickly abates once the movement ceases, the chsorder is at reasonably stable stage. If pain remains worse for hours after a relatively trivial movement, tne e1isorder may still be at an inOammatory stage Thus knowing if tne pai n remains worse or better afterwards nas important implications for self-treatment procedures.
If uncertainty
e x i sts as to
whetner a condition is s pi nal or peripheral,
the activities that produce or aggravate symptoms may also be helpful in determin ing the source of the problem Does con tin ued use of th e a ffe c te d a rea in crease, decrease or ha ve no effe ct on your pain ? In certain cases, pain
felt initially with activity diminishes and then
stops after a perio d of Lime, even though the activity is continued. Although the pain may reappear later, this sequence of events indicates the value of repeating the movements or activities involved. Converse ly if pain progressively increases, the indication in this event ,
is [or immediate cessation of th e movement or activity, especially if it remains
w o rs
e after Should the activity have little or no effect on the
syrnptoms at the time of application, there is no indication that the activity should be avoided.
1 00 I C H AP TE R
FIVE
T H E H U MAN EXTREM I T I ES: M EC H AN I CA L D IAG NOS I S
&
TH E RA I 'Y
It is n o t u n co m m on fo r pa ti e n t s with musc ulosk e l e Lal p ro b l e rns to d escribe s t i ffn e ss and a c hing firs t thing in t he m o rn i n g or a fter re stmg w h i c h a b a te s with ge n t l e a c t iv i ty. S u c h p a i n b e h a v i o u r may be d u e t o d egenerative J o int co n d i t io n s but equally hap pe n s in h e a l i ng ,
co l lagen ous tissu e that has been insu fficie ntly re mode l le d . Whate ver
i ts cause it i n d i c a tes regu lar movement a s being an a p p ro p r i a Le part of manageme n t . D o you ha ve pain i f th e lim b o r p a rt is re laxed a t res t ?
I f t h e p a t i e nt d e sc r ib e s t h a t ly ing i n b e d o r resting o r re l a x i n g L h e a ffe c t e d p a r t s t o p s h i s o r h e r s ym p t o m s , the p re s e n c e o f
an
i n fl a mm a t o ry s o u rc e o f p a i n i s e x c l u d e d . H o w e ve r , when all m e ch a n i c al stresses a re rem ov e d but the a ch i ng c o n tinues u n a b a t e d , i t must be due to inflamma t i o n , de rangeme n t or s e r io u s p a t ho l o gy I t is n o t u ncommon for ce rtain m e c ha ni c al c o n d i t i o ns to w a k e p e o p l e a t n i gh t . T h i s may not be t h e r e s u l t o f i n n a m m a tory p a m
b u t d u e to me c h a nica l stresses . F o r i n s t a n ce , t h e a d o p t i o n o f c e n a i n p o s i t i o n s wh i l e in b e d
,
s u c h a s l y i n g o n t h e s i d e , p ro d u c e s
comp ressi o n o f t h e s h oul d e r whi c h c a n b e p a i n fu l i n c a p sul itis or
ro tator cuff p roblems, w he re a s lying in a di ffe re n t posi tion is p a i n le ss Can you find a positio n tha t s tops your p a in ? If so, plea se describ e .
A l th o u gh the pain may have b ee n re ported to be constan L , a question c l a r i fyi ng the situ a t i o n is he l p fu l as o ft e n the p a t i e n t w il l re p l y t lL a t
i f , fo r i nstanc e , th ey re st t h e a r m b e h i n d t h e n e c k , p a i n i n t IL e s h o u l d e r c e ases . Do you g e t b e tte r or wo rs e a s the day progresses ? Is it a p roblem a t n igh t ?
P a t i e nts who e x p e ri e n ce im p ro v e m e n t a s the d a y p rogresses a re u su a l l y a l r ead y i mproving g e n e ra l ly a n d the re port m a y be rega rd e d as a si gn o f go o d p ro gnos i s . M us c u l o s k e l e ta l c o n d i t i o ns fre q u e n t l y res p o n d
a d v e rsel y
t o t h e enfo rce d res t o f nighttim e . S u c h p a t i e nts
r e p o r t tha t u p o n waking they are s t i ff and p a i n fu l fo r a w h i le , b u t
that a s the y become active d u r i ng t h e d a y the a c h e im proves . T h e ) ' c e r ta i n l y re q u i re e d u c a t i o n i n a p p ro p r i a te a c t i v i t i e s a n d increased
e x e rc i s e leve l s .
I f p a t ie nts re p o rt tha t th e i r condition w o rse ns t lL ro u g h o u t t h e d a y t h e n their n o r mal activities a r e aggra v a t i n g t h e p ro b l e m , a n d t h e se may need t o be tempora r i l y re s t r i c t e d o r a d a p te d .
C H A P TE R F I V E
H I S TO R Y
I t i s i m po r t a n t t o e nqu ire i f p a t ie n ts are w o k e n a t night b y t h e pro b l e m Va r i o u s c o n d i t i ons a re particularly trou bles om e a t n i ght shou l d er co n d i t i o n s and carpal tunnel sy n drome , for ins tan c e o ften ,
w a k e p e op l e . T h i s i s a no t he r fu nctional aspect against which to j u d ge
manage men t e rficacy at a later stage . Ha ve you h a d a ny pre vious tre a tm en t fo r th is episode ?
The d e t a i l s o f a n d respo nse to any p revio u s trea tmen t , 1 f a ny has
bee n rece i ve d , s h o u l d be b r i e fl y e n q u i re d abou t . Ha ve yo u e ve r had this problem b e fo re ?
1I- the p a t ie n t re p o r t s h a ving ha d similar sym p to ms in the past t his may i n dic a te that p o o r repa i r of the initial i nj u ry has p re d i s p ose d the a lTe cted stru c t ures to re p e a t e d fai lu re . I t is also p o ssi b l e that d e ge ne ra t i v e cha n ges h a ve l e ft t he tiss ues weakened an d p rone to
fa i l ure VI/h e re t he p ro b l e m is o ne o f recu rren c e , part i cular a t te n t i o n m u s t be gi v e n t o ed u c a t i ng t h e patie n t so t h a t t h e y a v o i d aggra va t in g or causa t i v e lac t o rs . The i r m a nagement m ust a lso include appro p r i a te gra d e d e xe r c ise s to try to re m ed y the u n d e r l y ing tissue a bn o rma li ty a n d weak ness . Wh a t tre a tm e n t was given fo r th a t problem ?
D e L e rmine w h a t p re v i o u s t re a t m e n t may h a v e b e e n p ro vi d e d [or s i m i l a r prob l e m s i n t h e past If the tre a t m e n t was passi v e , did t he con d i t i o n re spo n d t o L h a t tre a t me n t o r was the re c o very p rolon g e d o v e r t h e p e r i o d 0 1 t he n a L u ral h i s t o ry ? IF re c o v e ry fo llowed the use o f
m e d ica t i o n or N S A I D s , i t may b e appro p r i a t e fo r t h a t t reatme n t to be re p e a te d in c o n j u nc t ion with ac t ive manageme n t H o w e v e r, such man age me n t may not h a ve re stored the fu l l fu nctional i n te grity of t he t i ss u e , which wil l nee d to be evalu a te d . I f a regu l ar e x e rc i se
p rogra m m e h a s n o t been prev i o usly imp lemen t e d then this may be ,
needed fo r the fu tu re manage m e n t o f t h e p ro bl e m . Do you get back or n e ck p a in ?
I f the h I s t o ry p rovid e s li ttle or no e v i d e nce to indicate a peri p he ral p ro b l e m , m e c ha n i c a l assessmen t of t he neck o r bac k i s ne e d e d to e x c l u d e t h e spi n e as t he si Le o f p a i n ge ne ra ti o n
.
Previous spinal
p ro b l e m s , t he s i t e of t he pain , the presence of p a raesthesi a and the agg r a v a L i n g and re l i evi n g fa c t ors ma y raise the mdex of suspicion co n ce r n i ng the sou rce of sy m p toms D i ffe re n t ia t i o n b e tween neck and sho u l d e r problems can b e d i ffi cu l t . I t s h o u l d be re m e m b e re d tha t these p rob l e ms fre qu e n t ly o c c u r toge t h e r (van der W i n d t et a J 1 9 9 5 ) , a n d tha t cervical c o n ditions
1 1 01
1 02 1 C H A P TE R
FIVE
T H E H U MA N E X T RE M I T I E S : M E C H A N I CAL D I A G N OS I S
&
T H E R A I'Y
c a n p resen t c l inica lly as appare n t ' s h o u l d e r' p ro b lems ( G r i ev e 1 9 93 : S ch n e i d e r 1 9 8 9 : Wel l s 1 9 8 2 ) The p rese n c e o f a
c o n co mi t
a nt neck
c o ndition a t prese ntati o n h a s been rela t e d to a h i gh r isk of p e rsiste n t shou l d e r p ro bl e m s ( v a n d e r Win d t e t a l . 1 9 9 6 ) T h e s i t u a t i o n may arise that both pro blems need a dd reSSin g or that one site is t he sou rce ,
of the i r m aj or com p lai n t One m e thod of d e te r mi n i ng the re l e v a n c e o f the sp i nal c o m p o n e n t o f a p rob l em is to obse rve the mec h a nical p resentation of the shou l d e r b o t h b e fo re a nel a fte r p e r fo rm a n ce o f re p e a te d cervical move me nts . If t h e s h o u l d e r move me n ts i m prove o r worsen , clearly tre a tment needs to s tar t with t he s p i n e . [[ a s pi n a l p ro bl e m is p res e n t a n a p p ro p ria t e s p i n a l mecha n i c a l e v a l u a tion sh o u l d be carri ed o u t (McKe nzie 1 9 8 1 , 1 9 90) A re yo u ta king any m e dica tion for this proble m ?
F i n d ou t what me d ic a t i o n and w h a t amou n ts p a t i e nts a re c u r re n t l y taking for t h is p ro b l e m and fo r an y other p ro b l e m s . A l a t e r d e cr e ase in their qu antity of me d i c a ti o n wi ll b e a n o t he r s i gn of i m p rove m e n t Ask a b o u t t h e e ffec t o f t h e me d i ca t i on on t he i r p ro b l e m . P a t ien t s are gene rally well a w a re i f medication is he l p i ng or h a v m g n o e ffe c t , and a t e m p o r a r y or l a s t i n g i m p ro v e m e n t i Appropr a te p a i n m e d i ca t i o n such a s p a ra ce t a m o l ( o r i n t h e U n i t e d
if h e l p i n g w h e th e r it is
S t a t e s ace t a m i n o p he n) m a y b e s a fer a n d m o re c o s t - e ffe c t i ve t ha n N S A l D s ( H oc h be r g e t a l . 1 9 9 5 a )
Medica t i on is a l s o l e s s t i m e i c o n s u m in g a n d n many cases m o re co s t - e ffec t i ve t h a n the p ro v is i o n o f ph Y S i o t hera p y S o m e d o c tors p resc ribe a c o u rse o f N SA l D a t the sam e time as re fe rri n g t o phYSio t he ra p y, b u t t h e s o u rce of a n y i m p roveme nt i n symp t o ms i n s uc h a s i tu a t i o n i s co n fU S i n g
.
A l s o , the d i s p e nsa t i o n o f med i c a t i o n does n o t nec e ss a ri l y mean t h a t th e rec o v e r y o f full fu nc t i o n will fo l l o w Some pa ti e n t s may have ta ke n various cou rses of ta b l e ts which have b ro u g h t tem p ora ry re l i e f ,
bu t t h e p ro b l e m always se ems t o rec u r : a t th i s time t he y may be keen to try a longer- l a s t i n g s o l u t i o n lo r the i r p r o b l e m i n v o l v ing e d u c a t i o n and ac tive manage me n t . / s y o u r genera l hea lth g o o d o r poor?
Re p o rts of ill h e a l th or feel in g u nwell c o u ld in d ica te the p resence o f o the r fac t o rs whi c h may be o f h ighe r p ri o ri ty t h a n a musc u loske l e ta l
p ro b l e m Re fe rra l fo r fu rt h e r i n vestiga t i o n is d e s i rable u n cl e r such .
c i rcumstances .
C H A PTE R
H I S T O RY
Have you been x-rayed for this problem ?
Ra d io l o g i c a l or i ma g i ng stu d ies a re not req u i red in the e a rl y sta ges o f t r e a t ment for m u s c u l o s k e l e t a l p roblems w i th the exception t h a t a n y si gni fi can t tra u m a m a y c a u s e fractures in w hich case radiological sc reen ing wil l b e requ i red O therwise , in the eve n t t h a t responses to m a n a geme n t a re p o o r, o n l y the n m i g h t s u c h i n v e st iga tions be consi d e red .
Concl usion I t c a n b e he l p fu l a t this poi nt b riefly t o s u m up your u nd e rstand i n g
o f the p roblem to the p a tien t - h a ve you got a correct i n terpre tation of their p re s e n ta t io n ? What was the mode of onse t ? How long they h a ve had the p rob l e m ? I s it constan t or i n termitten t? What makes it b e t ter and worse ? I t will help to fo c u s o n the key elements of the con d ition . A ft e r t a ki n g t h e history cert a i n e lements of the clinical p resentation sho u l d be clear. It w i l l be k nown wha t site or sites w ill ne ed to be loo k e d at in the physical e x a m i n a ti o n . In the case of some
peri p h e ra l con d i ti o n s , d i fferen t i a t i o n fro m spina l p roblems may nee d fu rther e l uc i d a t i on d u ri n g the mechan ical assessm e n t . The ti me scal e -
and o n se t will be know n , ,vh ich s houl d g i ve an i d e a abou t the l i kely
staLe of t he a lTecLed tissues - whe t h e r they are damaged and in flame d , hea l ing, a b normal o r deconditioned . A recent trau matic onset shou l d ale rt t h e clinici a n t o t h e possible nee d t o p roceed cau tiously with the mec h a n i c a l e v a l u a tio n This can be summarised as an acute , su b acute o r c h ronic cond i tion The h isto ry w i l l a lso re veal if the pain generati o n is cons tant or i me r m i tten t . This gives a v i t a l clue to the n a t u re of the p rob lem , w h e the r it is c h e m i c a l l y o r m e chan i cally mediate d , a n d o ft e n also to
the p rognosis There will be an imp ression o f the way the patient has re s p o n ded to his or h e r prob l e m - whether, for instance , t hey are
anxious or fea r fu l of c a u s i n g fu rt her d a m a g e and the refore restrict the i r a c t i vities in a d e trimental way.
FIVE
1 1 03
1 04 1 C H M'T E R Figure
T H E H U M A N E X T R E M I T I E S : M E C H A I'\I I C A L D I A G N O S I S
FIVE
T h e McKe n z i e I n s t i t u t e P e r i p h era l
5.1
& T I-I E I�! \P Y
Assessment she e t : histo ry-gathering
TH E M c K E N ZI E I N STITU T E P E R I P H E R A L A S S E S S M E NT
.I
Date
. . .1 . . M
N a me . Ad d res s
Date o f
Work
/
/F
.
birth .
. . / ..
Ag e
. . . . ./ . .
Leis u re
Postu res
/ Stresses .
F u n c t i o n a l d i s a b i l i ty from p r e s e n t e p i s o d e
SYMPTOMS H I STORY P resent symptoms Present since
I m p ro v i n g /
. . .1 ..
. . . . . .1 . .
U n c h a ng i ng
/ Wors e n i n g
. . or no a p p a r e n t reason
Commenced as a res u l t of . Symptoms at o n s e t .
Constant
I n t e rmittent symptoms .
symptoms
What p ro d u ces or worsens . .
What stops or reduces .
Pain
Yes
at r e s t
/
No E H e c t
No
Yes
Distu rbed n i g h t
Worse
Better
C o n t i n u e d use makes the p a i n
/
No
O t h e r q u estions .
Treatm e n t t h i s
e pi s o d e
...
P re v i o u s episodes . . P r e v i o u s treatment o o o N
.
S p i nal h i s t o ry . . P a raes t h e s i a
'" c
Q ;;; c
Medicatio n s : tried
a;
Prese n t medication
"
G e n e r a l h ea l t h .
E
�
"5
Effect
Imaging . Summary : Sites for
Acute
/
Sub-acute
physical examination .
/
C h ro n i c
Tra u m a
/
I n s i d i o u s onset
Yes
/
No
O-IMHR SIX
6: Physical Examination
I ntrod uction The mechamcal assessment s h ou ld relate closely to the findings from
the initial inLerview. From the history p rov i d ed by the patient, the clinician will already have formed conclusions regarding the likely
origin 01 the sy m ptoms The cl in i ca l examination is des i gned ro .
conl·irm the initial findings and fully expose the mechanical nature and extent of the problem. The two parts of the first day's assessment should thus pro d uc e a good general picture of the patient's sympLOmatic and mechanical presentations From these findings will
come the optimal management of the condition. It also provides baseline measures of pain, movement and function against
which to
establish the value of any subse qu ent intervention. The infor mation also gives p rog n ost i c indicators, derived from s u ch items as the duration of the problem, the previ ous h isto r y the age of the patient ,
or the constancy of the pain. The e x a mi nati on format and sequence
described here can be a pplied to the articular and motor elements in both the upper and l ow er limbs. The p hy s ical examination i n vol v e s various observations and movements about which the clinician must make judgements. It should be re m e m b e red that such perceptual tests, in which a human be i ng is the m easur i n g device, are bedevilled by variability of results. Intraobserver and interobserver variability is seen as the inevitable consequence of such perceptual tests (Gray 1997)
Although this
phenomenon cannot be total ly prevented, its impact can be limited
by con d u cti n g the e xami na ti on in the same way each time it is done. Clinicians need to perform tests consistently on eac h occasion, and patients must always start fro m the sa me pos i ti.on In th is way we can be more certain that d i ffe rent rest results renect chan ges in the
me cha n ical presentation rather than bei ng the fault of inconsistent examination technique. Frequently if the symptoms are in the shoulder or hip areas it is essential first LO h a ve ruled out spinal sources of pain. The effect of Single and repeated end-range spinal m ovem ents on symptoms and
on the mechanical presentation should b e noted. If c e rvi c a l movements affect pain at the shoulder or improve a painful arc, clea r l y
1105
1061 CHAPTER SIX
THE HUMAN EXTREMITIES:
MECHANICAL
DIAGNOSIS
&
THERArY
the spine needs to be addressed first. However, concomitanl neck and shoulder problems are common and at times both problelTls may need management strategies With the information gathered from the patient's history, the physical examination should allow differentiation into one 01- the three mechanical syndromes, a chemically mediated pain or a chronic pain syndrome. Using passive resisted and repeated movements, vve can further differentiate between symptoms that arise from peri-articular or contractlle structures_ If the cause is found to be articular, then mechanical therapy will most often be targeted at end-range movement restriction in the case of dysfunction, or end-range movement obstruction in the case of derangement. Il the lesion affects contractile structures, treatment of the dysfunction will reqUire repetitive loading in m id- range The mechanical evaluation will also indicate the preferred direction in which to apply loading, the precise point in the range where loading
must be targeted, the amount of loading to be applied to the affected structure, and the frequency of its application. It will also be determined from the assessment whether or not the patient will require assistance to achieve the desired effect or whether it is vvithin the patient's capacity to manage his or her own recovery
Aims of physical examination Using the form and the appropriate testing procedures at the end 0 f the phy sical examination, Ideally the following will have been obtained: classi [ication into i nnammatory, postural, d y sfunction, derangement or chronic syndrome inconclusive and needing further mechanical testing over a few days baseline measurements of symptomatic and mechanical presentations, functional disability, and present analgesic and
NSAID consumption against which to Judge effects of management strategy explanation of problem to patient and reason for required exercise programme
CHAI'TER SIX
PHYSICAL EXAMINATION
time scale for improvement explained to the patient appropriate loading strategy, or strategies, needed to manage
the co n di tion demonstrated to and practised by the patient the repetitions and regularity of exercise programme explained to the patie nt
expect e d pain respon se explained to the patient. Observation The affected pan should be uncovered and examined for signs of redness, he a t, swe lling bruising or abrasion. Localised redness, heat ,
or swelling will indicate the presence of an inflammatory response to tr a uma or infection W here genera lised joint swell ing is present, .
e spe cial ly if bil a t e ral and in the hands, feet, wrist s or ankles
,
rheumatoid arthritis may be suspec t ed (B erko w et al. 1987) Where indicated, such patients should be rderred for appropri at e m an agement
.
Mechanical evaluation The affected structures require a me chanical evaluation to determine
the effects that various movements have on the pat ient S symptoms '
In order to stress the J oints and relevant surrounding soft tissues in a control le d manner, test movements should be applied in the sequence described below. The information gained from the history and this mechanical evaluation should allow differentiation between problems that are mechanically or chemically m e diated Subsequent to this, .
ddlerentiation is mad e between o ne of the three mechanical sync! romes
.
To explore t he relationship be tween exercise and t he pa t ie n t s symptoms, test movements must be performed in such a way that '
they prod uce
a
change to those sym ptom s This change may be
e xp ressed in various ways 1f prior to movement pain is present, the test movement may increase or reduce i ts intensity ; it may alter the
location of the pain by abolishing one pain and introducing anoth er. If prior to movement no pain is present, the test movements may produce the pain. C han ges that occur during test movements may remain better or worse
afte rw a rds or may return to the former level
of p a i n Prior to the appl i cation of each of the various mechanical
tests required for the assessment, it must be established and recorded whet her or not pain is already present. The consequences of various mechanical load ing forces are determined by comparison of 'before
1107
1
081 CHAPTER S IX
THE HUMAN EXTREMITIES: MECHANICAL DIAGNOSIS
&
TJ-IERAI'Y
a n d after' levels of pain. See C ha pt e r Seven for a detailed descripti on o[ the evaluation o f sy mptoma tic responses to l oading s tr a t egies
1f there is no change in the pa tient's sym p to ms during or immediately following th e test mov emen ts, it may be that the structures have not been stressed ad e qu ately. 1f so, the process should be repea t e d more vigorously. It co uld also be tha t the pain is no t of mecha n ical ori gin , because me chanical pain must be and always is a ffecte d by movemen t s or po sitio ns Alternatively, the structures under a ssessmen t may not be causing th e symptoms and othe r areas s h o uld be investigated, most importantly the spin e
Role of palpation The mo st effec tive way to assess the s ta te of a joint or musc l e i s throu gh testi n g function E xplori ng the symptomatic res p o nses to
different loading s trate gies d o e s this. P alp a t ion offers nothing
extra
in the assessment of funct ion . In rep eate d studies of manual t he ra pi sts' palpatory skills in the s pine, poor intertes t er rella b il i ty has consistently been shown (Mootz et al. 1989; McKenzie and Taylor 1997; Binkley et al. 1995) Palpation for tenderness can be very m isle a d i n g due to the phen o me n a of primary and secondary hyperalgesia, and is gene rally unnecessary. It may be used to dete r mi ne warmth, s wel lin g,
or feel for cre pitus during Joint movement . However, this should always come a fter the functional assessment so that p al pa tio n mere l y endorses the examination find ings rather than servin g as
a
mea ns 01"
establishing the site of lesion.
Use of the assessment form The p hysical examination part of the assessment she et allows sel e ction of moveme n ts in different planes - (1exio n, extens ion, adduction ,
abduction, lateral rotation , me d ia l rota ti on , etc. The amo un t o f loss of movement should be rec orde d a s minimal, m o derate or major, or e l se range of movement can be record ed in d egrees. The effect or re peated movements should be re cor ded in the normal way (see
Chapter Seven [or a d escription of the standardised terminol ogy to be used to desc ribe symptomatic re spons e s ) If t he re is pain during the movement or
a
pai n ful arc, the PDM column should be tick ed ; if
it is e nd- range pa in only, ERP should be ticked. The example below d emonstrates h o w a part o f the form might be used in describing
a
shoulder jOint dysfunc ti on or 'frozen sho u lder' . The pan of the form rel ati ng to the phys ical examination is at the e n d o f this chapter
PHYSICAL EXAMINATION
Table 6.1
CHAPTER SIX
Description of a shoulder joint dysfunction
PERIPHERAL Observation Active
movement Loss
�\e .... \C:(l-
\"3<::,'"
POM
'nand be.n,,,,,,, nae.\< Passive movemont Loss (+I·over-pf(�ssure)
-c.
"",-,""r.l:Y..>.lI:ock.
�.
POM
Resisted tests Response \'C>
pa\1'\
El1ecl 01 repealed lests on pain'
produces. radiates,
�\e.)(....iO:-' Eltecl 01 repealed
leSIS on movement:
ro
ert'e.C-.\;
abolishes. localises,
increases, bel1or,
\?,odwc..��,,.
Beller
decreases,
worse,
no beller,
no
worse.
no eHecl
n.a .. ...::::.cC::.Y::- . Worse
No Effect
L Test movements used will be as follows. Not all test movements need
be used every
time: active movements; passive movements (+/-over
prl'ssure); res i s t e d m ov e m e nt s , re p eate d movements; sustained postures Active movement
From the h isLo ry, Lhe paLient will h av e described the general di rect ion and nature 01 t h e movement or move me n ts prodUCing the most pain. The examination will idemify the precise d i rect ion of movem ent that provokes or aggravates t he symptoms. From examination of the movement involved, it 'vvill be possible to identify th e anatomical locati on of pain as it occurs. This may assist in the se a rch for the origin of the problem in an adpcent articulation, m usc l e or tendon.
The range 01 active m o vem e n t and the presence of p a i n must be noted in difl'erent planes of movement. Movement may be full or
reduced; compare with the o th er limb if in dou bt. M ove ment may be pain-free or pa i nl"ul during the moveme nt (PDM) or at the end range of move men t (ERP) Record findings for each movement on the assessment sheet. End-range pain is commonly se e n in p e ri p he ral musculoskeletal conditions Comracted tissues that prod u ce pain when stretched m a y
limit m ov e m en t s ;
in
t hi s case the range achieved with passive
movemen t s 01" the li m b will be very s imil a r to the ac ti ve range Limited active and passive m ove me n ts , which are painful at end-range, are characteristic of capsular co nt r ac ti o n and scar tissue that has not
1109
1101 CHAPTER SIX
THE
HUMAN
EXTIUMITIES: MECHANICAL DIAGNOSIS
& THERAPY
been ad equately remodelled. Degenerative c h a nges can leael to restrict i on s m range of movement, for instance loss of extension and flexion at the knee ( A ltma n et al. 1986; H ayes eL al.
1994;
BiJI et al.
1998), or flexion, medial rotation and abd uction at the hi p (Di ep p e 1995). Peri-articular problems such as 'frozen shoulder' produce simil ar movement restriction; in t his condition especially flexion,
abduction and lateral and medial rotation Uacobs et al. 1 9 9 1) The more severe the degenerat ion , the more likely it will be that sign i fi cant
active movement restriction will be found. These restrictions are what
Cyria x (1982) termed capsular patterns of move m e m loss, which he considered to be outwa rd signs of arthritis in a Joint from any cause. His d e S Criptions of p ropor tional movement losses in set p atterns have not been validated (Hayes et al.
1994; B�l
et
al. 1998) M ovemen t
losses occur, but in in div iduals with hip ost eoarthritis this has been shown to be in all six directions of movement, not the set pattern desc r i bed by Cyri ax (Biil et al.
1998)
E nd - range pain
is a lso
a
characteristic of traumatisecl tissue which has heaJecl with COnLractures or adhesions that limit nonnal flexibility Rather than pain bein g p ro d uce d at end - rang e , it may be produced
or aggr avated during the movement. Pain durin g be produced because of a problem with
a
a
movement may
cont racti le structure or
because of an articular prob lem. An arc of pain in mid-range is due
either to the compression of irritated soft tissues by a bony constriction or to an articular internal deran ge m e nt . Painful arcs occur quite frequently at the shoulder, where it is thoug ht to indicate co nst ri ctio n of abnormal tendons or bursa. They are also seen at the knee and l umbar joints, indicati ng internal derangements (Cyriax
el er Windt
et
1982;
van
al. 1995) Degenerative con d itions can produce pain
during movement. Passive and resisted move me nt te sti n g will clarify the situation. In a few very severe cases active movements may be Jimited, while
passive movem ents are full or cannot be fully tes t ed because of extreme pain. This sort of presentation is seen sometim e s at the shoulder in e ld e r ly patients Active movement is almost always a painful experience wh e the r the problem is ar t icul a r or musculotendonous in origin. Exceptions may be found, however, where inj ury has occurred to ligaments restra i n i ng the non-voluntary movements. These structures are best lesled using passi ve movement tests with overpressure (see appropriate section)
PHYSICIII EXAMINATION
Active movement summary
Pain produced by active movement is mechanical and can be articular, ligamentous or musculotendonous in origin. Active movements can provide us wi th the following: mechanical presentation (range of movement or willingness to move) which can be used to evaluate management symptomatic presentation that can be used to evaluate management whether pain and/or stiffness limits movement (passive movements may be needed also to confirm this) arc of pain, which has diagnostic implications, for instance irnplicating tendons or bursa at the shoulder end-range pain, which has diagnostic implications, generally implicating articular or peri-articular structures. Passive movement
Movement perlormed passively does not rely on contraction or loading of musculotendonous structures for its completion. Thus these tests stress non-contractile structures in and around the Joint
and tend to implicate articular or peri-articular structures, and tissue contraClures in any connective tissues. Pain may appear during the passive movement or at the end of range; it may be due to articular
derangement or dysfunction Passive movement, which produces end-range pain in a restricted range of movement, is characteristic of dysfunction. As discussed in the active movement section, this may be in the soft tissues around a Joint, as in the restrictions seen in osteoarthritis of the hip or capsulitis at the shoulder, or it may be found when stretching healed, scarred tissue following trauma. For instance, in someone who has injured his or her calf muscle, but failed to remodel it adequately during healing, dorsiflexion would be limited, stiff and painful. A painful
arc
occurring during passive movement, with or without a
painfullimitalion of movement, occurs in derangement. In this case,
when end-range overpressure is also painful, the attainment of end of range is obstructed by dislocated tissue or some anatomical disruption in an articular structure. To distinguish between end-range pain due to derangement and that due to dysfunction, two options are available. vVith repeated
CHAPTER SIX
1111
1121 Ci-tArTER SIX
TH E HUMAN EXTREMITI ES: M ECHAN ICAL DIAGNOSIS & Til ERArY
movements t he re will be no change in the symptomatic response in
dysfunction even if the movement is repeated a hundred times a day
for several weeks - pain of dysfunct ion only changes slowly as the tissue remodels. Given the slow turnover of collagen this takes tirne, usually to be measured in weeks and months rather than days. With derangement repea ted movements will change the pain
It may
worsen on repetition, in which case the opposite direction should be explored, or it may improve - the key differentiation is that it wilJ
not be consistent every time as it will be with dysfunction. Overpressure may also be used to distinguish between the two syndromes (see next section). In patients who have recently injured a muscle resulting in the
for m ati o n of a haematoma there would also be pain on passive m ove m ent
testing Such patients also present with pain appearing
towards the en d
-
r
ange of passive movement. Distension of muscle
consequent to the swelling prevents normal elongation of the a ffected
muscle Passive end-range movement in such cases is always painful, but the site of pain will occur near the location 01 the haematoma
and away from the Joint Passive movement summary Passive movements stress the n on c o n t ra ctil e tissues, for instance -
Joint capsu l es and intra-articular contents. They also test the flexibility
of any connective or contractile tissue after trauma. Tissue that has healed without a de q u ate remodelling may be symptomatic and tight
when t hat shortened, scarred tissue is stretched Passive
movement
tests can be useful to confirm a restricted range of movement if accompanied by reproduction of th e patient's symptomatic complaint, it may result from internal articular derangement or from tissue dysfunction (for example, capsular COl1lracture or unremode 1led scar tissue) •
repeated movements and overpressures aid differentiation if passive movement is full, but accompanied by reproduction
of the pat ie n t s complaint during the movement, articular '
derangement is likely
Passive movement with overpressure There are various instances in which extra force applied at the end range of normal active or passive movements may proVide additional
C Ii A PTE R S IX
PIi\'SICAI. EXAMINATION
information. As n o ted above, ove rpre ssure can be used to help distinguish belween end-range pain due t o dy sfu n ct i o n or derange ment. In dysfunction once the pain is produced more p res sure
will produce more pa in, but this will rapidly abate once the s tress is released. In deran ge me n t the application of more pressure will either increase or decrease the pain and bring about a las ti ng change in pain, either worse or better. There are also ins tan c e s in which other mo v ement tests fail to reproduce the patient'S pain. In some less acute articular conditions, pain may not be provoked by active movement or during the passive tes t i ng sequence. Pain may only be elic i ted when o v erpres sure is
a pp l i ed at the end of the range. Due to soft tissue appos itio n , active movements at c e rt a i n joints fail to reach end-range; this occurs with Ilexion at the hi p or knee. In such in s tances passive movements with overpressu re are more informative. Overp ressure, can, if excessive,
cause pain in normal a rticula tions. It is important therefore that the pain rep0rLed is the 'familiar' pain and not a str a i n' pain caused by '
excessive force. Overpressure should be applied at first with a gentle
firmness Lhat may increase gradually with two or three re p eti tions . If the c onditi o n is articu la r familiar pain in one or more directions ,
should be reported.
Where limiLation of movement is moderate to s e ve re , the passive end-range 'feel' can be described either as a 'bony' or 'hard' obstruction, or a 'rubbery' or 'soft' obs truc tion
It is unlikely that
attempts at recovery of movement will be success ful when the end feel is 'hard'. A 'soft' end feel, on the other hand, is indicative of a malleable tissue that may respond to remodelling. When
a
p a ti e n t describes that normal voluntary movements are
painless, iL is unlikely that the problem will be identified u sing active, passive or resisted move m ents. Where voluntary movement through
full range is painless, it is likely that th e patient experiences pain on Iy when a pO S I tion is
a
do pted or external force is ap p l i ed against
or across the planes of voluntary motion peculiar to that joint. Testi n g
articular ligamentous structures that prevent n on-voluntary m o ve ments at the Joint may Identify the source o f pain. I ns ta n ces of this are the varus and valgus forces u sed by clinicians to test medial and late ral collateral ligaments at the knee and elbow. See, for instance, Evans (1986) or Magee (1987) for thorough descriptions of the se l i ga men t stress tests. In both these cases it becomes necessary to
1113
11
4/ C HArTE R S I X
THE HUMAN EXTREMITIES: MECHANICAL DIAGNOSIS & TIIERAPY
identify the direction of pain provocation in order to structure the appropriate management programme This usually requires manual overpressure in the required plane and will vary from one Joint to another.
Passive movement with overpressure summary In assessing the pain response from any articulation, it may be necessary to apply overpressure at the end-range of Joint motion if other movements evoke no painful response. Overpressure is also useful in the following instances: the end feel may be a prognostic indicator, with
a
'hard end
[eel' being unlikely to respond to a remodelling programme •
to help differentiate dysfunction from derangement to provide ligamentous stress tests at right angles to the normal plane of Joint movement.
Resisted tests Resisted tests load the tissues involved in contraction and thus test for any painful impairment of contractile structures
-
whether muscle,
tendon or periosteal insertion. By ensuring that no mOlion occurs in the adjacent articulation at the time of applying resistance to the muscle group, the experience of any pain occurring during this test is likely to arise from the contractile structures alone A posilive resisted test i.s the production of the patient's pain complaint All other resisted tests should be pain-free, or virtually so, and passive movements likewise, excepting one (see below). Weakness will often accompany the pain. It is essential that the limb to be tested be completely stabilised and
all movement prevented. Any disturbance of the limb that occurs invalidates the resisted test result as pain may arise from other than contractile structures. Examples of these tests are illustrated, for instance, in Laslett (1996) and Cyriax and Cyriax (1997) Resisted movements should have no effect in the presence of articular derangement or articular dysfunc tion, or where capsular or ligamentous structures are the source of pain as long as all movement is prevented. Resisted movements will provoke pain in the presence or dysfunction or trauma affecting the contractile structures of the extremities. The pain will be elicited immediately when the loading is sufficient to deform the structurally impaired or inOamed tissue. In some instances
C H APTER S I x
PIIYSICAI. EXAMINATION
small amounts of resistance will provoke severe and ra piel pain, while on other occasions strongly resisted movements wlil only just gener ate e noug h l o a ding to be fe lt . In more s evere ca s es p a i n may be accompanied by weakness and
a
giving way of resistance as the
loading stresses the da m age d tissue.
Because of the large excursion of motion ava ila ble to most joints of
the extremities, t hey require len gth y contractile elements in order to fu n ction ef fi cientl y This anatomical construct prov i des abundant
opp o rt un i ty [or co n tractio n or adhesion formation during the repair process following inlury Dysfunction developing from i m perfect repair of injured IT1U scle or tend on will p rovo ke pain whenever t h e
structure is s u bj ecte d to loa ding , irr e sp e ctive of whe re in the range of movement t hat loading may occur. Thus t he patient may report
Lhat pain will appear whether loading is applied at the innermost, at mid-range, or at the outermost po int in the range. Pain will a lso appear during eiLher concentric or eccentric loadi n g D y s functi o n of con trac ti le structures will pro duce pain when the t iss ue is loaded in m i d -range with t he appropriate re s is te d test.
Muscles and tendons also have to be a ble to stretch as well as c ontr act
.
Thus it will be found thaL s t re tc hing the dys function a l tissue, either ac ti vel y or p aSS ive ly in t h e oppOSite direction from its contractile ,
role is painful also. For in s ta nce , in dy s func t i on of the hip a dd uc t o rs
in
a
'
gro in strain', both resisted adduction an d en d ra nge abduction -
will be painful Resisted tests summary
Tissue loading of contractile st ructu res achieved through re sis ting ,
and preventing a certain movement, can isolate impairment of th ese structures by reproducing the patient s symptoms All other movement '
must be prevented.
painful res i s ted tests indicate the involvement of muscle, tendon or p uios leal i n sert i on pain less res i sted tests exclude the possibility of the involvement of contractile strucLures stretching the muscle unit is also likely to be painful. Repeated movement or loading
Repeated m ovem en ts when a p plied to an inn.ammatory disorder, or when a pp lied too early or too Vigorously to an injury tha t is h ealin g
,
\115
116
1 C H ArTE R S I X
T H E H UMAN
wil l p ro d u c e
EXTRE M ITI ES:
a
D I AG N OS I S
M E C H A N I CA L
&
T H E RA PY
l as t i ng i n c rease in the pain , a nd m o v e m e n t m a y
b e c o m e m o re d i ffi cu l t . Repeate d m o veme n ts w hen a p p l i e d t o
a
chro nic disord e r may p ro d u c e a t e m po ra ry i n crease in sympto m s . Re pe a te d movements w h e n a p p l i e d t o mec h a n i c a l d is o rd e rs o f t h e muscu l o skele t a l system ev oke d i ffe re n t responses w h e n a p p l i e d t o t h e three syn d ro m es a n d thus can be d i agnos t i c . ,
The t w o main m echan ical s yndro mes fo u n d i n c l in ical p r a c t ice a re d e ra n geme n t a n d d y s fu n c t i o n . D i ffe re n t i a t i o n be t w e e n L h e m i s impo r t an t because the m a nage m e n t fo r d e r a ng e m e n t req u i re s t h e a p pl i c a t i o n o f mo vement that reduces the p a in , w hic h o cc u r s as a c onseque nce o f the re du c tion o r the derange m e nt . On t h e o t h e r h a n d , d ys fu nc t io n re q u ire s th e ap p li ca tion o f movem e n t th a t p rodu ces the s y m p t o m s , a re q u i re me n t fo r s t i m u l a t l n g t h e re m o d e l l i n g o f c o ntrac t e d o r adherent tiss u e . As menti o n e d p re v i ou s ly, re p e a L e d movemen ts a re key to t h i s di ffere n ti a t i o n D e ra n g e m e n t s c a n d e m o n s tra t e l a s t i n g a n d r a p i el c h a n g e s i n
sym p t omatic a n d me c h a n i c a l pre s e n t a t i o n s i n s hort pe ri o d s of ti m e with re p e a t e d moveme nts . Pain aris ing fro m i n t e r na l l y de r a nge d a n d dIs p l a ced a rticu l a r tissue i nc reases or d e c reases acco rd i ng Lo w h e t h e r t h e d i re c ti o n o f rep ea t e d m o v e m e n t i n c reases o r d e c re a s e s the d i s p l a ceme n t . Thus re p ea te d m o veme n t s wI I ! cause t h e p a i n LO
i n c rease i n one d ire c tio n a n d de c re ase in t h e oLhe r, o ften w i t h a c o nc omitan t c h a nge in ran ge . A fter t h e test movemems L h e res u l L i n g p a in re mains wo rse o r remains b e t t e r accord ing l y. In d ys func tion the t i ssue a bnorma lity is n o t ame nab le to ra p i d c ha nge . I t re q u ires re m o d e l l i ng over weeks o r m o n t h s , a n d
c o n S i s t e n tl y to re p e a te d mo ve m e n ts
.
T h e c s s e m i a l n a t ur e o f a
d ys fu nc t i on is its consistency. Hund re el s o [ ITIOVements over
a
i t res pond s
a
d a y repeated
wee k o r m o re w i l l pro d u c e the same p a i n t hat the pa t i e nL
complai ns o f t i me a fte r ti m e . vVhen t h e s t ress is re moved t h e pain
will a b a te within minu te s . There will be no lastmg change Re p e t i t i o n s \Nill ne i ther m a k e the p a i n inc re a s e nor d e c rease i n i n t ensity ; i t wi l l b e the s a m e each t im e . The m o ve me n t t h a L p roduces t he p a t i e n t 's p a i n may b e a ctive , p a s s i v e , p a ssive wi th o v e r p rc s s u r e o r res i s t e d d e pending on t h e n a ture o f th e dysfu nc t i o n . A pa r t fro m d i ffe rentiating b e tw e e n d er an ge men t a n cl d y s fu nc t i o n synd rome s , repe a te d moveme nts are essential in deLe rm i n i n g w h e t h e r
C H A I' T E R S I X
[" H Y S I C A L E X A M I N A T I O N
the t i me is a p p ropri a te to com mence st retc hi n g procedures fo l l ow ing t rau ma
.
'Nhen repeated m o ve menLs a pp l i ed
in a given d irec tion
prod uce l ess a n d l ess pain w i t h e ac h re p e t i t i o n , exe rc i se in th a t d i re c t i on is i n di c a t e d I f re p e ti ti v e l o a d i n g fro m the s a m e mo ve m e n t .
pr o d u ces p a i n at m i d - o r e nd ra n ge t h a t ceases on u n loading , exercise -
in that d i re c t i o n i s also i n di c a ted
I f p a i n p rogressively inc reases
d u ri n g re p e a t e d move ment , e x e rcismg in t h a t particular direc tion is n o t inch c a Le d . I f p a i n onl y worsens i n part of the ran ge , repeated m ov e menLS a re i nd i c a t e d for tha t pa rt of the range that is p a inl ess or to t ha L pa r t i c u la r p o i nt in the range that does n o t worsen the pain .
Re p eated m o v e ments that cause the pain to be worse a fterwards may i n d i c a te t h e re - t rigge ri ng of the i n fl a m m a t o r y response in sub-acute c o n d i t i o n s Howe ver, i n the event that pai n is aggravated follovving
re p e a l e d m o v e m en t in a p a rti c u la r di rect i o n , re pe a ted movement in th e op posi t e di rec tion s h ou l d be explored . 1 f the cha nge in d i re cti o n brings a bouL a red u c t ion in pain , t he derangement syndrome must
be c a u sa t i ve and t he re d u c tive m o vement has been identi fied . I n c h ro ni c p a i n s y n d ro me s i n whic h t issues a re d ec o n d i tio n ed a n d hype rsensi tive , t h e re ma y a lso b e an initial wo rseni n g of pain w i th re peated m o v e m e n t s . However, under t bese circumstances , t h i s s h oul d n o t be i n Lerpreted as a contraindication t o active mechan i cal
t he r apy Re p e a t e d m o ve m e n L s should a lso al ways be us ed when synd rome c l a s s i Cica t i o n is unce rtain and d i agnos t ic a cum en is l o w In these i n S L a n ces
t he r e s p o n se to re p e a t ed movem e n ts allows dete rmi n a t i o n
o f th e a p p rop r i aten ess o f an exe rc i s e p ro g r a mm e . I f following certain move m e nt s t h e p a t i e nt is no worse or better, re g u l a r per formance of
t hose m o ve menLs is i n d ic a t e d to im prove fu nctional i mp a i r ment. If t h e patie m is worse fol l O W i n g al l movements , then restoration of
func L i o n m u s L s t a r t m ore ge n t ly It is n o t necessa r y or e v e n d e s i ra b l e to c o nd u ct repeated movement testing i n a l l d i recLio ns T h i s ma y aggra v a t e the prob le m and obscure the va l ue of symp t omatic re s p o nses For each con di tio n onl y certain d i re c t ions s h o u l d be i nv o l v e d in r e p e a t e d movement testing T he p la n es o f m ovemen t to be testeel in t h is way are m ost like ly to be
those t h a t i n v o l ve t h e gre a te s t i m p ai rm e n t ; this may be loss of mo v e m e n t
or
p a i n on resisted tests. T hus r epea te d m o vement testing
1 1 17
11 8 1 C H A PT E R S I X
T H E H U M AN E XT I U M I T I F S : M E C I-I A N I C A L D I A G N O S I S
&
T I-I E RA l'Y
will vary b e t w een c o n d i t i o n s and be tween i n d iv i d u als and w i l l be guide d by re sponses to the earl ier p a rt of t h e mec h a n i c a l e v a l u a t i o n . Repeated movement in the pos tural syndrome
Whe n ap p l i ed to patients w i th the p o s t u r a l sy n d ro me , re p e a t e d movement has n o ef fec t and all li nd i n gs w i l l be n e g a t i v e In th e postural syndro me , pain on ly arises in the a ffec ted a rea a lter p ro l onge d s tatlc load i n g . Repea ted mo vement in the dysfunction s yndrome
In the d y s fu n c tion syndrome , n o pai n w il l be fe l t at re s t . Rep e a t e d move ments o r t issue l oadi n g will c a u s e pai n wi t h eac h re pe t i t i o n :
the a p p ro p riate tiss ue l o a d ing may be a c t iv e a n d p a s s i v e o r res is te d T he p ain will cease on u n l oadi n g . End - ra nge p a i n with l i m i ta t i o n o f m o ve m e n t will indicate a n a rticular o r caps u l a r o ri g i n (o r pain P a i n felt d u r ing re p eated static load ing o r du nng part o r t he w h o le a rc o f full m o ve m e n t i n d i cates a c o ntrac tile o r i g i n fo r t h e s y m p t o m Pain ma y i n c rease s l igh t ly w i th ten o r t w e l v e re p e t itio ns , but u s u a l l y subsi d es ra pi el l y and re mains neithe r b e t t e r n o r worse as a res u l t N o rap id c hanges i n p a i n o r range o f m o t i o n wil l occur. Repeated movement in the derangement syndrome
I n t he case o f de range m e n t pai n may rap id l y re d u ce
or
c e ase and
remai n b e t ter fo l l ow i n g the ap p l ica ti o n of re p e a te d m o v e m e n ts ap p l i e d i n t h e d i re u i o n t h a t re d u c e s t h e d e g r e e o f i n t e r na l d e ra n ge me n t . At t he same time , re peat e d m ov e m e n ts w i l l be s e e n to re d u ce the d e gree 0 1" the o b s t ru c t i o n to m o ve men t . Sym p t o m s can a l s o be m a d e to increase a n d r e m a i n worse fo ll o w i ng re p e a t e d m o v e m e m a p p l i e d i n t h e d i r e c t i o n t h a t i n c re a s e s i n t e r n a l d e rangemen t . Simultan e o u s i n c re a s e in the obst ru c t i o n to m o v e m e n t wi l l also occur. T h i s clear- c u t i n d i cat i o n o f the d i re c t i o n fo r t h e
a p p l i c a t i o n o f t h e r a p e u ti c m o ve m e n t i s k n o w n a s ' d i re c t i o n a l prefere n ce ' , a term coined b y Donelson e t a l .
(1 9 9 1 ) , a n
orthopae d ic
s u rgeon invo lved in re s ea rc h and prac t i ce 0 1" me c ha n ical d i agno si s and thera p y.
The d irec t i o nal p r e fe rence i d e n ti fi e d i n p a t i e n t s w i t h t h i s s y n d rome prov ides a rel iab l e gu i d e whe n d e t e rmi n i n g the m o s t a p p ro p r i a t e t h e rapemic exercise p rogramme . Provi d e d t he red u c t i v e m o veme n ts are p ra c t i sed and the causative m o ve m e nts a v o i d e d fo r a fe w d a ys ,
p a t ie nt s witb the d e range m e n t sy nd ro me are rapid ly re sto re d t o lu l l pain- free func tion
C H A rH R
P H Y S I CA L EX A M I N A T I O N
Summary Table
Directional pre fe rence
6.2
The response
to
rep eated m o v e m ents
Imp l ication
n o p a in d u ri ng re p e a t e d movemen ts
Postu ra l Syndrome
p a i n pro d u c e d o nly a L limite d end
Dys function Syndro me
range , no wo rse afterwards
( p e r i - a mcular)
pain produced only by res i s te d tes ts ,
Dys fu nction Syndrome
no wo rse a f t erw a rd s
( c o n tra cti l e tissues)
i n c reasing sym p t o m s in o n e dire c ti o n
Derangement
dec re a s i ng sym p toms i n t h e o t h e r
Synd ro me
a l l d i re c t i ons cause l a s t i ng increase
Chem ical p ain
i n pain
in su b-acute con d i t i on
p e r si st e n t pain in which initial a c tive
Chronic pain s t a t e
the rap y causes som e te mpora ry aggrava tion o f symptoms
Neurolog ica l exami nation D u r in g t h e c ourse o f h i s t o ry tak in g a n d m ec h a n i c a l evalu a ti o n , -
i t is
some t i m e s the case that a sens o ry o r m o t o r d e ficit is no te d That is , the prese n c e o f t i n gl ing or numbness may be voiced by the pa tient , o r wea kn ess not a t tr ib u t a bl e to p a i n , or loss o f reflexes m ay be fou nd o n e xa m i n a t i o n. . T h e m o s t l i kel y o r i g i n o f s u c h n e u ro l og i c a l im pa irment is the s p ine Rad i cular p ain in the a rm or leg wil l also be presen t , a l t h o ugh s pina l p a in may no t. Te nsion tests such as straight l e g raise , neck flexi on or uppe r l imb tension tests a re also likely LO ,
be posi t i ve . S o m e t i mes these tests a re p OS i ti ve wHh o u t the sens o ry or m o t o r d e fic i ts U su a l ly t h e s o u rc e o f these proble ms is the spine
and exa m inatlo n. and m a nagem e n t s hou l d b e directed at this area by cond ucting
a
n o rmal mechani cal eva l u a t i o n (McKenzie 1 98 1 , 1 990 ) .
Occasi o na lly a thorough ex a mina tion and testing o f the spine i s unable to offe r a c l e a r sou rce o f the s y m p toms In these i nstan ces fu rther
examination o f neu ra l tension tests ma y sti l l une arth mechan icall y ' se n sit i sed neu ra l tissue , which upon testing re p roduces the patient s pain . B e fo re using t hese te sts in t rea tmen t it is essential to ma ke su re tha t b o t h s p i n a l a nd l o c a l articular s t ru c tu res are not involve d in the
SIx
11 1 9
I
1 20 C H A rT E R S I X
T H E H U M A N E X T R E M I T I E S : M E C H A N I C A L D I A G N O S I S & T H E RA r v
pro bl e m - b o t h wi l l make t hese te sts fa lse p o si t iv e The tests used i n the upper arm a r e d e s c r i b e d i n B u t l e r ( 1 99 1 ) , as is t he i r use . G re a t care must b e ta ken i n t h eir use , as it is v e ry easy t o aggravate sensi t ised n e u r a l tiss u e . It is possib le , again w i t h care , to use m o ve men ts based o n thes e tests fo r sel f- t reatment .
Concl usi ons T h e c o l l e c t i o n o f i n fo rm a t i o n fro m t h e h i s t o r y e xa m i n a t i o n a n d ,
m e c h a n i c a l eval u a t i on will ind icate w h e t he r the p a t i e nt is su ffe ring fro m t h e p ostural , dysfu nc t i on or d e ran ge m e nt syn d ro m e , o r
a
n O ll
mechan ical cause . The differentiatio n i s necessa ry, a s t he t re a t me n t
o f e a c h w i l l be c o m p l e t e l y di ffere n t . I n p a t i e nts with t h e p os t u ral s yn d ro m e , fo l l O W i n g id e n t i fi c a ti o n 01 t h e causative factors , adj ustme n t La t h e posi t i on o r postu re res pon sI b le [-o r the sy mptoms is a l l t ha t is req u i re d In those p a tients w i t h
the dysfunction syn d ro m e i n t he i r trea t m e n t ,
t h ose m o v e m e nts a re a p p li e d t h a t i n the e x a mina t i o n prov o k e d t he i r p a i n . When a p p l i e d fo r t re a tm e nt o r remodelli ng p u r poses , i t is i m p e ra tive that s o m e pai n be e x p e rienced d ur i ng e x e r c i se T h is is p a r t i c u l a rl y im p o r t a n t in t h e i n i t i a l s t a g e s of t re a t rn c n r w h e n c o n t ra cted st ructures m us t b e s t re t c h e d enough t o assist t h e m to re m o d e l to t h e i r o ri gi n a l length and rega i n the i r fo r m e r e lasti c i ty P a t i e n ts in tre a tm e nt fo r d y s func t i o n m u s t e x p e r i e n ce s o rne p a i n o r disc o m fo r t . A n art icular dys function w i l l requi re end - range s t retc hes . A d ysfu n c t i o n o f c o n t ractile stru c tures wi ll req u i re re s i s t e d m i d - range l o a d i ng a n d end-range stretches i n the o p p o s i t e d i rec t i o n fro m i ts c o n t r a c t i l e rol e . In those p a t i en ts with the dera ngement syndro m e , i n t h e i r t rea t m e n t are a p p l ie d those moveme n t s w h i c h i n t h e examinat i o n
reduced ,
s t o p p e d o r loca l ised the pain . Pre d ispos i n g p o s t u res o r m o v e me n ts
w i ll be i d e n t i fied so tha t the pati ent may avo i d re c u rrence a n d
Ln
t h a t eve n t apply sel f-trea tme n t I f l a s tin g aggra vation o f a recent c o n d i ti o n res u l ts fro m re p e a t e d m o v e m e n ts fu r t h e r re l a t i v e re s t may be nee d e d, o r o n t h e n e x t occasion a m o re ge ntle movement o r d i fferent starting pos i t i on should b e use d .
C H A PT E R S I X
P H Y S I C A L E X A M I N AT I O N
I n t h e case o f c h ronic co ndi tions a n init i a l temporary aggravation o f sy m p t oms a fter com m e n cing exerc ise i s quite common . This shou ld
be exp l a ined to p a t ien ts a n d shou ld no t be so great as to deter t hem fro m fol low i n g the necessa ry p rogressive recondi tioning p rogramme . I n c o n c l u s i ve res u lts
F o l lowi ng the comple te mech a nical assessment of the u p per or lower e xtrem i t i es, i f it is not possib le to reprodu c e or a ffect the p a ti e n t 's sy m p tom s , i t may well be that the so urce of p a i n lies within t he sp i n a l c o l u m n a n d is e i t her referred or rad iating from the spi n a l se gme n ts. To exc l u de t he sp ine as a ca use o f p a i n experienced in t he extremi ties , a mec h a n i c a l eval u a tion as desc ri bed in The Cerv ical
and Tho rac i c S p i n e: Mechanica l D i agn O S i s and Th e rapy ( M c Kenzie 1 9 90) o r Th e L umba r S p i n e · M e c ha n i c al D i a g n o s i S and The rapy ( M c Kenzie 1 9 8 1 ) should be applie d . Followi ng the sp i n a l assessment p rocess, i f no move ment or position has been fo u n d [0 a ffec t change
in the symp tom a t i C or m e c h a n i c a l p resenta tion i n the periphery, the c o nd i l l o n is u n l ikely to be caused by mechamcal musculoskele tal d i so r d e rs. It m a y be necessa r y to re fer t he p a tien t for fu rt h e r in vestiga t io n . A fter the h i s tory a n d e xa m i nation have been completed it may a p pear a t fi rst t h a t the p rognosis is not e ncou raging . [ t is a mistake LO prov ide the p a t i e n t w i l h t h is c l i n ic a l i m p ressi on b e fo re we h a ve h a d c o n fi r m a ti o n o f o u r p re d ic tion from the resu lt o f a trial period of m e c ha ni c a l assessmen t over a fe w d a ys I t is not a lways possib le for
t he p rognosis t o be so certa in . The refore it
is best to avoid giving a n
incorre c t i m p ression o f the n a t u re a n d e x te n t o f the p roblem before t h i s is fu l l y a p p a re n t . Howeve r, once it is c lea r t h a t the n a t u re o f the p rob l e m is su ch t h a t mec h a n i c a l t hera py wil l have l i t tle o r no impact on the condi tion , i t is i m portant t h a t a realist i c p i c t u re is conveyed to t he pa tient . Th is , d lows t he p a t i e n t to come to terms with a persiste nt p roblern a n d a lso m a kes i t more l i ke l y tha t they w i l l a d o p t the ne cessa ry stra tegies for m a n a ging i t in the best possi ble way P ro longed p h ysi o t hera p y c a re for i n t ra c t a b l e p rob l e ms I S certa i n l y a waste o f resou rces � i t i s also b a d p r a c t i ce a s i t detracts from the need to e d u ca te p a t ien ts to manage persistent pain sta tes in t he op t i m al way
1 1 21
1 22
1 C H A P TE R S I X F i gu re 6 . 1
TH E
H U M A N E X T RE M I T I E S :
M EC H ANICA l.
D I A G N O S I S & T H E RA P Y
The M c K e n z i e I n s t i t u t e Peripheral Assessm ent s h e e t : p hy s i c a l exa m i n a tion
PERIPH ERAL Observation
Active move m e n t Loss
PDM...
Passive movement Loss
.. ERP .
..... PDM
E R P . . . . .. . . . . . . . .. . .
(+/-over-pressu re)
Resisted tests Response
Effect of repeated tests on p a i n :
produces,
abolishes,
radia t e s ,
Effect o f repeated t ests on movement ·
local ises ,
i n c reases, bette r,
decreases ,
worse,
Better
no belt e r,
Worse
Static POS i t i o n i n g Effects
Loaded / U n loaded
SPINE Move m e n t Loss . .
E ff ect o f repeated move m e n t s :
E ff e c t of s t a t i c position i n g :
Spine testing:
Not relevant
CONC LUSION
/
R e l evant
/
S e c o n d a ry p rob l e m
P e r i p h e ral
Spine
D y s f u nction : A rt i c u l a r . . .
C o n t ract i l e
Derangemen t
Postu ral .
Other .
U nc e rt a i n
PLAN Exercise
Frequency
no wo r s e ,
no effect
N o E ffect
7: Assessment of Symptomatic and Mechanical Presentations and Responses Introduction At tne first assessment and on all subsequent occasions clinicians
must be evaluating the patient's p roblem and th e effect o f the management s tr a t eg ie s being used. Tnis evaluation n eeds to address botn the pain, which is freq u en t ly the patien t s main compla im and '
,
the impaired functi on The two elemems should be evaluated on .
each oc c a sion and generall y improve or worsen in tand em - in other worels, if the pain eases the function should also improve. Dep ending
on the ellect of the management strategies these should be cominued, abandoned or sup p lemented with overpressures or possibly clinician
tec hn iques.
Symptomatic presentation Pam is usually the main complaint of patiems with musculoskeletal pro bl enls
,
a
l tho ugh paraesthesia, numbness or weakness may also
be relevant Pain as an o u tcome measure is criticised as 'so ft' data,
which lacks objectivity However, while pain is by its very nature a subjective experience, it can be
recorded and
assessed in a reliable
way, especially when using serial measuremems of pain taken from a
Single individual (Sim anel Watefield1997) Numerous articles and books present w ays of assessing p ain and some of the associated
problems (for instance,Jaelad and
McQuay 1993; Sim and Wateli eld
1997; Adams 1997) The most common tools are rating scales of pain intensity or relief, visual a nalog u e scales, analgesi c consumption, pain frequency and pain questionnaires that in v esti gate multi dimensional as pe cts of pain Uadad and M c Q uay 1993)
For any
tnerapeutic intervention whose goal is the red uc tion of pain, the
assessment 01 pain must rank as one of the most important and relevant mea sures of improvement (Holmes and Rudland 1991). Pain has various dimensions by whicn changes can be assessed
Temporal component A patient may complain of constam pa i n [[ this subsequently becomes inlermittem an improvement has been made. It' an in term i tte nt pain which is present for most of the d a y is reel uce d LO being present only twenty per cem of the day, Lhis also is an i m p rov e ment
.
CHAPTER SEVEN
1123
1241 C/'IArnR SEVEN
THE HUMAN
EXTREMITIES:
MECHANICAL
DIACI'IOSIS & TJ-IERMY
Site. Pain of spinal origin may centralise or periph er a lise (Donelson et al. 1990,1991). The further the pain s p read s into the limb, the worse the presentation; if the area of s ym p tOlns can be reduced t hi s is an improvement Radiation of pain also commonly occurs from some peri p heral joi nts, especially the hip and should er Cy r i ax (1982) propo sed that the spread of .
symptoms was part ly a reD ec tion of the stren gth of Lhe painful stimulus As the noxious sLimulus increases, Lhe pai n becomes
more diffuse and spreads distally - referred p ain from the hip can spread to the antero-medial shin, and [rom the shoulder into the hane!. A re v e rsal of this process, and L h us an improvement, is pain localised to the particular joint
-
thus
localisation is the peripheral equivalent of the spinal phe nomen on of centralisation. Severity Intensity of the pain can be assessed in various ways This can be done for mally using a Visual Analogue Scale, with
the paLient marking the pain i nte nsi ty on
a line b etwee n 'no
pain' and 'pain as bad as it could be' (Huskisson 1974) They can be asked the same question at a later date for comparison to determine whether the pain intensity is se vere, moderate or mild. Alternatively at re-assessment pa ti ents can be askeel how their present symptoms compare to when they first at te nded
.
'If you had 100 units of pain when we commenced treatlne n t -
how many do you have novv)' Some patients even volunteer that they are '80% better'. Consump tion of analgesics and NSAlDs The nurnber o[ tablets
being taken daily at the beginning of the episode should be recorded and compa red with consumption laLer Pain on movement Even if movement appears to be full-range,
pain may be felt during Lhe movement or
at
end-range. An
improvement is made if the patient reports that over time the difficulty of performing the movement and the degree of discomfort it engenders has lessened.
Alth ough very often pain responses are a u sefu l deLerminant of appropriate mecha n i cal therapy, it should also be born in mind that excessive attention to the pain can heighten the pain response (Arntz
et al. 1991). By contra st use of distraction techniques can minimise ,
the pain (Klaber Moffett and Richard son 199'5) With some patients
ASSESSMENT OF SYMPTOMATIC AND MECHANICAL PRESENTATIONS AND RESPONSES
the focus should be on function rather than pain; this is especially relevant in patients with persistent pain problems.
Mechanical presentation and its assessment The mechanical presentation refers to the outward manifestations of the problem that may limit or alter normal movement and posture.
The mechanical presentation has vanous dimensions by which it can be assessed. Broadly these address the issues of impairment and disability. Impairment refers to abnormality of normal physiological function because of the problem, while disability IS the ensuing restriction of normal function. The dimensions are: loss of nomlal range of movement ddormity (more common in spinal problems) deviation o[ movements velocity of movement; pain often makes people move more cautiously, and return to normal speed represents a n
improvement (McGregor e t al. 1995; Paquet e t al. 1994; Magnusson et aL 1998) loss of normal function; for instance, abstinence from usual sporting activities, inabiliLY to perform normal domestic tasks or absence from work
The assessment of Lhese changes is relaLively straightforward. Range of movement Lests should al'vvays be conducted from the same starting posillon and in consistent ways so that the results can be compared on different occasions. More formal ways of assessing the patient's function should be done using established disability questionnaires relevant to different joints. These questionnaires, completed by the patients, are a very good measure of treatment efficacy and address issues relevant and important to both patient and clinician. Examples of such questionnaires are given below:
Table 7.1
Disability questionnaires
Shoulder
van der Windt et al. (1998) Croftetal. (1994)
al. (1998)
Knee
I rrgang et
Lower extremiLies
Bin kley et al. (1999)
CHMTER. SEVEN
1125
1261 CHAPTER SEVEN
THE HUMAN EXTREMITIES: MECHANICAL DIAGNOSIS & THERAPY
Assessment of the symptomatic presentation Standardised terms (McKenzie 1981; van W�men 1994) are used to evaluate the pa tien t's pain responses dur i ng mechanical testing The
pain status is established before, during and after test proced ure s If we wish to compare t he effect of movements on the symptoms it is vital we know the pain status prior to testing- it is too late to establish this once the patient has sta rted to do the m oveme nt s We are most .
in te res t ed in the
effect of the movements a minute or so after Lesting_
At baseline the patient is eith er with or without pain During the Lest movements this can be increased, decreased, abolished or p roduced The significan t response which will help determine the treatment strategy is not, however to a S ingle movement. The key symptomatic ,
response follows repeated movements when different terms are used to describe any changes_ At this point pain which was incre a sed
or
produced by the movements can either rem a i n worse or be no worse; while pai n which was d e crease d or abolished during the movements can ei th er remain better or be no better: [f during and a fter the movements the symptoms remain completely un c ha nged they are smd to have no effect- These terms are listed and defined in the glossary
Use of symptom responses to determine loading strategies Using these standardised terms to define the patient's responses to repeated movements allows us to d e term i ne the appropriateness of those p a rtic ular movements_ A system called the Traffic Light GUlde, d evi sed by Wand J Rath (Robinson 1994), addre sse s the Lherapeutic implications of the pain resp onse after the test movements. The Traffic Light Guid e allows a l ogi c al formulation of appropriate mechanical l oading strategies based on the patient's symptom responses. If the patient is better after the test movements, or in the case of d ysfu nc ti on if pain p rodu ced by movement ceases when the stretch or contraction is re leased the c orrect movement ha s been ,
selected and treatment should be con tinued unaltered. This IS a 'green
light' to more of the same procedure. If the patient is shOWing imp rovements with the prescribed management, there ;s no justification for changing or sttpplementing it in any way.
ASSESSMENT OF SVMrTOMATIC AND MECHAI'iICAL
PR.ESENTATIONS AND
R.ESI'ONSES
Table
7.2
Traffic Light Guide
Pain status
Pain response
Pain
prior to test
during test
after test
lncrease
Worse
h,"� � ___
Implications (Traffic Light Guide)
Red
�NotwOtOC_Amber Decrease
Abolish
No Pain
response
Green
Better
�
Produce
NOL Better
___
Reel
Worse
�
Amber
Not Worse
Amber/Green
__
If the pain remains worse after test movements, then either the direction or speed of movements is wrong and that particular exercise should be stopped Movements in the opposite direction should be tested as we1l as lateral movements. If mo v eme n ts still aggravate symptoms, non-mechanical problems might be suspected Movement
may be sLarting too early during the h eal i ng process and the inflammatory process is being reactivated, the wrong starting position is being used, or the procedure may be too vigorous for the stage of th.e disorder This is a 'red light' to that particu l a r procedure. If everyth.ing appears to aggravate the patient's symptoms, they should be spared further testing and reviewed in a week's time. If a similar response is generated with mi nimal t esting
,
the diso rder is
inappropriate for mechanical therapy at this stage. In the case of th.e 'amber l i g ht' , essen tially nothing is changed by the
test movements. Alth.ough they may produce, increase, abolish or decrease symptoms at the time, afterwards the patient repor ts that they are Just the same as they were before This allows the application of more force to see if the traffic light changes to give a clearer indication of the appropriate direction of therapeutic exercise. Only with an 'amber ligh.t' re spo nse is it justifiable to use force progreSSions, altho . patient exerCising more regular l y, or with patient overpressure, or it may involve clinician force if this is thought to be
n ece s sar
y In
dysfunction this response is a green li ght for that particular exercise. '
'
If pain is produced on con traction of contractile structures or on
CHAPTER. SEVEN
1127
1281 CHArTER SEVEN
THE HUMAN EXTREMITIES: MECHANICAL DIAGNOSIS & THERArY
end-range stretch of peri-articular structures which ceases on release, that loading strategy should be continued unaltered. Most conditions will fit into one of the above caLegories, especially if the problem is of recent onset. If symptoms have been presenL for some time the response may be the equivocal 'amber light'. IL is often helpfu l at this point to get the patient to test oul
a
specific procedure
for one or two days and gauge the response following this. Other ways of facilitating the diagnostic process when it is unc le a r
are (van
Wij men 1994) •
ensure that movements are to end-range
•
apply mechanical forces more vigorously
•
sustain postures
•
increase the number of repetitions
•
increase the fre que n cy of repetitions
•
use alternate starting positions
•
stress the Joints in one direction and check the effects on pain and movement range in the opposite direction
•
test provocative p ro cedures over two to three clays.
Chronic pain In the situation of chronic pain when peripheral tissue and central nervous system elements may be sensitised ancl cleconcl itioned Lo normal movement, the criteria of symptom response needs to be different. Under these circumstances normal
m
e c h a n i cal slimuli can
produce pain, repeated movements may have a 'vvind up' effect on pain production, there may be a spread of painful areas, and there may be ectopic nociceptive Signals (Dubner 1991: Johnson 1997) These changes make the interpretation of mechanically produced symptom responses difficult and invalidate diagnostic labels app lied to particular responses (Zusman 1992, 1994) These examples suggest that we should interpret the behaviour of chronic pain to repeated movements somewhat less rigidly Non-mechanical factors may be more Significant than sim ple tissue abnormality The above effects are unlikely to be present to the same degree, or even in all patients with chronic pain: some such patients respond
ASSESSME>JT OF SVMI'TOMt\TIC AND MECHANICAL PRESENTATIONS AND RESI'ONSES
straightforwardly to mechanical therapy. Some patients with chronic pain can have ongoing tissue damage or a degenerating disease Uohnson 1997)
Most patients with chronic musculoskeletal pain
have only mild or moderate symptoms and do not suffer major functional impairment (Magni et al. 1990; von Korff et al. 1990); many also will leave the pool of persistent pain sufferers if followed ov er
a
few years (Crook et al. 1989). Only a small proportion of
patiems with persistent pain are at the severe, disabled end of the
spectrum: many will respond normally to a mechanical evaluation. If the response is equivocal, test out the patient's response over twenty-four hours or use one of the other suggestions above for facilitating the diagnostic process when it is unclear. However, in the instance of chronic pain patients, it is sometimes permissible to allow a slight worsening of symptoms initially. Sometim.es the response to mechanical therapy takes a while to elucidate, thus it is valuable to follow the approach for a few sessions rather than abandoning it as soon as there is a slight worsening of symptoms Sometimes the sensitisation induced by chronic pain states needs to be desensitised by encouraging gentle regular movement prior to establishing a more mechanical pattern of response. With chronic pain p a t i e m s it is necessary to concentrate more on trying to improve coping strategies and function rather than focusing on pain. Often improvement in general function and the psychological effect of doing something active about their problem can produce a reduction in pain. Patients with severe levels of dysfunctional
behaviour due to persistent pain problems are best treated in a multi diSCiplinary pain programme rather than on a one-to-one basis As has been discussed in Chapter Two, some chronic tendon problems represent a failed repair process in degenerated tissue in which the normal phases of h e al ing are suspended or absent. In these conditions a vigorous exercise stimulus can often re-trigger the process 01' healing
[nitiaJiy with these degenerated structures a
temporary aggravation for a clay or two is thus desirable. Once this reaction has been achieveclthe vigorous stimulus should cease, and a
graduated exercise programme should be instigated as for a sub
acute problem.
CHAPTER. SEVEN
1129
130
I CHAPTER SEVEN
TI-IE
HUJ'v\AN
EXTREMITIES:
MECHANICAl. DIAGNOSIS
&
THERAI'Y
Review process On the second day and at each subsequent visit, a slnlctured, l ogical and informative review process needs to be conducted. This is to
determine what the patient has been doing regarding previous instructions, the immediate effect of any procedures being done, and
if there have been any overall changes. Find out from the patient if as a result of follOWing the instructions there has been any change With doing the exercises over the last few days, is the patient better, worse or the same overalP
If the patient is better there
is no need to change management in any
way, and they should continue with more of the same If they are worse or unchanged they must be questioned more clos e l y about what they have been doing Have they been exercising? How frequently? What exercise have they been doing? Ge t them to show you.
However clear you think you may have been, patients unfortunately frequently 'modify' the exercise.
Are there any problems with this? What is the sym ptom response when they do the exercise) Check symptomatic presentation.
If there is a change, is this definite or doubtfuP Check if there is any change in functional problems. Check mechanical presentation
It will then be known how regularly they have been doing their exercises and if the y are doing them correctly Their technique may
need correcting, but wai t until you have heard hoyv it affects their symptoms - they may be doing it 'wrong', bu t it may be helpingl They ma y need encouragement to be exercising more regularly, or they might have been doing too much. If pa tients are having problems with the d emands of a regular exercise routine, the importance of doing it regularly needs to be emphasised.
ASSESSMENT OF SYMPTOMATIC AN D MECHANICAL PRESENTATIONS AND RESPONSES
Encouraging p atients to solve diffi cu lties with the regime or the exercise itsell promotes se lf-managemen t. Some patients are very reluctant to do th i ngs that hurt and are still very anxious about pain
res ponses They n e ed extra reassurance 'that hurt does not equal .
harm , that reduced activity is only briefly beneficial at the onset of '
pain, and that the only way to try to re-establish normal function is graded exposure to normal activity From the review you will also know their sym ptom at i c and mechanical response to performing exercises over a day or two they will eit her be better, worse or unchanged As outlined earlier
this gives a green light' for more of the same, a 'red light' or an 'amber '
light' respectively. it is important to ensure that they are actually in these states. Detailed q u estion ing and close analysis of symptomatic
and mechanical responses, as out l ined earlier, are so me times necessary to el u ci d a te the true picture. If the patient is better nothing ,
needs to be ch a nged, only encouragement given If the patient is worse, exercises and symptom responses need to be checked, but e nsure the patient is actually worse, rather than the exerClses simply 'hurt'. When starling any unfamiliar exercise programme new pains
rnay be generated. This is not unusual, but it may confuse the patient If un ch anged are they exerCising regu larly enough and doing the ,
right exercise? [s Corce progression necessary ? In the case of dysfunction no change would be expected, and they should be encou raged to conti nue Always ensure that the patient understands why they are doing what they are do i ng and are happy about doing it. Self-management demands that the patient is convinced; it is the clinician's responsibil
ity to convince them.
CHAPTER
SEVEN
1131
132/ CIIAPTER SEVEN
THE HUMAN EXTREMITIES: MECHANICAL DIAGNOSIS & THERAPY
CHAI'TER EIGHT
8: Patient Management
Introduction Patient management means the organisation, supervision and implementation or the strategies to be applied for the successful
education and treat m e n t of the patient. Clinicians will already have their own systems in place for patient management These systems vary, of course, but the broad principles outlined below remain the same for all. The patient has been questioned regarding the history of their
cOlnplainL. An examination of appearance and function of the affected region has been performed. The findings from the history and the
exarnination allow the patient to be classified according to
a
mechanical, chemical or chronic syndrome. From this c1asslfication the therapeutic management can be structured to suit the patient's requirements The thuapeutic management 'vvill consist first of an educational component and second, an active mechanical therapy component The educational component will provide the patient with an understanding of his or her problem and the role of movement in their rehabilitation, while the active therapy component will provide
them with instructions in the appropriate exercises.
Education component of management All patients have certain needs for information about their disorder from health care profeSSionals (Charles et ([I. 1997). In a group of patients attending their general p r actitioner in London, an 'explanation of t he problem' was the most wanted item during the
consultation (Williams et al. 1995)
However, doctors frequently
underestimate patients' desire for information about their condition
(Ong et cd. 1995) The failure to provlde adequate information is
a
common cause of dissatisfaction among patients in general, and among patients with musculoskeletal problems in particular CDeyo and Diehl 1986; Cherkin and MacCormack 1989; Fitzpatrick et al.
1987; Hall and Dornan 1988, Locker a nd Dunt 1978) The information thal patients want concerns four key areas (Williams et
al 1995, HaJl and Dornan 1988; Cherkin al. 1987)
et
al. 1991; Fitzpatrick
et
1133
1341 CHArTER
EIGHT
THE HUMAN EXTREMITIES: MECHANICAL DIAGNOSIS
•
in formation about the p roblem i L self
•
what patients can do to help themselves
& THFRAPY
information about tests diagnosis and imerventions ,
an idea about the prognosis of the p roblem . Patients' specific requirements fo r information will
ind ividu a ls and between presentations The de pth and detail 01 information given should be appropriate for that patient, but must be sure to cover the essentials t h at are necessary fo r the seH
management o f their problem. Essential components or the information provided should reassure p a tients anxieties and fears '
about the pain, and encou rage t he e arliest p ossible resLoration of function. Failure to proVide the a p p ro p ri a te information is l i kely to res ul t in patient dissatisfaction and will seriously unde n:nine the patients' ability to manage their p roblem in the optimum way Patient '
education should not be seen as a n ice extra , but as an effective '
trea tment in i tse 1 f. For instance, in the field of arthritis, individual studies document the ability of patient education to decrease pain, depressio n disability ,
and tender JOll1ts (Lorig 1995; M azz u c a et al. 1997) Evidence suggests these health care gains can be sustainecllong-term (Lorig et
al. 1985, 1993) Current meta-analyses suggest that pain, ten de r Joints, depreSSion exercise, coping behaviours and health s e rv i ces ,
'
use can all be improved by educational progra mmes for rheumatology pat ients (Lorish and Boutagh 1997) For patients with back pain, although the evidence c on ce r ning group educ a ti on a l programmes is
weak (Cohen
et
a1. 1994), more recent studi es have shown the value
of information provision and a self-management approach in reducing
sick leave and anxiety and improving seU-care and function (Indahl et
a1. 1995, 1998; von
Korff et
al. 1998) Two factors have been
identified that seem i m po r tam in ac hieving these beneficial effects They are improv ed self efficacy, which is the belief that people have -
about bei ng able to control aspects of t he i r life; and an internal health locus of control, which is the belief that they can affect their health without the help of 'external' others (Lo r i g et al. 1993� lndahl et af.
1998)
If the condition is of recent onset, a d escription of the healing and remodelling process should be given. The patiem must undersLand the nature of the environm ent necessary for tl1c creaLion of good
PAT I ENT MANAGEMENT
CHAPTER EIGI-iT
quality repair and the importance of a graduated exercise programme for the restoration of full function. Some explanation should be given abo u t the characteristic of scar tissue to contract with time and lack of movement. To create an ex t e nsi ble and strong repair, patients
should be encouraged to commence gentle movements in the first week, and progress as the h e a l ing tissue st reng thens Reassurance .
should be given about lhe pain, the prognosis, and any other particular con ce rn s that the patient has, so that fear-avoidance
behaviour does not retard the reparative p ro c ess Once the repair is .
well estJblished the patient should be enco u raged to restore any
restriction of motion and recover any lost function Treat Your Own
Strains, Sprains and Bruises (Lindsay
et
al. 1994) is an excellent
patient -d i re cted text on the sel [-treatment of many common injuries.
This book presents a st ru ct ured format by which patients can manage their own rehabilitation in a var iety of acute and sub-acme soft tissue injuries It olTers a brief overview of the healing process and gives
daily p rogress i ons of specific exercises. H the patient consults with a problem that has pe rsi sted for many months, they will olten have been avoiding moving the limb nonnally, fully or into the pain This behaviour may have been appropri.ate in the initial stage, but later is more likely to perpetuate problems Reassurance is v i t al to convince the patient that even t hou gh exercises may provoke their pain, they are not only appropriate but also an essential pan of their rehabilitation. The recovery of fu ll pain-free moven,ent must be the ultimate aim in the treatment; t he re fore all patients must learn the progressions of exercise necessary to achieve
total functional recovery. If the problem has persisted for some time, rapid changes in symptoms or mobility will be less likely in some conditions. The patie n t should be in . formed gradual change in their condition, and this should not be used as an excuse to i m plemen t passive treatment modalities of dubious worth
Finally, the patient must be instructed suffiCiently so that he or she can, in the future, avoid rec urre nce of the problem In t h e event of recu r rence they must know how they can minimise the consequences. If complete freedom from symptoms is not attainable patients need to be acquainted with the optimal self-management strategies that allow them to cope with their p roble m in the b est way possible. Thus patients have a significant role to play in their own rehabilitation only they can in nuence the state of the ti ssues repeatedly and regularly
1135
1361 CHAI'TER
EIGHT
THE HUMAN EXTREMITIES: MECHANICAL DIAGNOSIS & TIIEkIlI'Y
day after day, but they need to be ed u ca ted in the appropriale behaviours.
If cl ini c i a n s are to become educators it is necessary to be aware of some of the tools involved in education. G ivin g the patient too n1uch in for m a tion especially on the first visit, will be confu sing . What are ,
the most important messages you want to ge t across? K ee p them to a
minimum and be c lea r about them. Repeat t hem several times If the patient is having p rob le m s graspi ng so me thing get them to repeal it ,
back to you. Explain again using a different example. Use pat ien t
friendly l angu age and avoi d bei ng judge men tal - this is likely to antagonise them r at her th an mak e the m re ce p ti ve to your message When tea c hing exercises and appropriate symptomaLic responses, s h o w them what to do first, then get the m to do it and repeat it. Performance mastery of a task is the most effective way of influ enc in g
self-efficacy and adherence (O Leary 1985) Action - getting patients '
to p e rfo r m an e x e r c i se - is
a
b e t t e r t e a chin g model than
demonstration, information or persuasion Talk through the pain response, givi ng the explicit assurance that i t s al l r ig hl if iL hu n s a '
bi t. Check that the patient knows what they are do i n g before they leave. As well as provid ing a model of pain behaviour thaL i s
acceptable, warn them about excessive aggravation of symptoms LhaL is not acceptable, and when they should sLOp However, if we give the pat i e n ts all the a n s wers they totally rely on us and are less likely to maintain control of their p ro b l em afLer the inte rve nti on has fi n i shed 1t is important to geL the palients to solve
their own difficulties and dil e mmas as much as possible and get them to work through how individual problems can be tackled. One way to do this is to give them options; for instance, al ter nati ve ways of
avoiding pos tural stresses or o v e rc o ming pro blem s c o nc e rn ing maintenance of an exercise regim e Patients who are reluctant to .
follow a p rogram me can be offe red the choice of doing it and changing their present state or not doing it and remaining as they are. The
more they can cope without health c are p rov ide rs the more theif independence is enhan c ed In effect the episode of Lherapy should .
be a process d u r in g which i nformation and stra t egi es are d i scu s sed and control is gra dually ceded to t he p a t i e n t, so that at di scha rge they feel confident that they can manage their probl e m e efe c L ive ly
a n d inde p ende ntl y
PATIENT MANAGEMENT
CHAPTER E I GHT
Active mechanical therapy component Patients wish to have bOLh an understanding of the problem and to know what they might do to help themselves Once an explanation has been prOvided o[ the role that exercise has in res t ora t ion of normal function, iL is then necessary to show the pa t ien t the active mechanical therapy component of their self-management. The specific exercises shoul d be demonstrated to the paLienls with instructions to practice these The expected pa i n response should be explained, as well as any warnings against lasting aggravation of their condition. As necessary, progressions and alterations should be given. In certain chronic conditions a temporary exacerbation of symptoms is possible
and necessary prior La any improvement. The situaLions
in which
this is relevam will be noted in the text. In most circumstances exercises should be repeated about ten times eac h session. Initially, to test LhaL the response is satisfactory, these should occur three or four Limes a day Once the safety and appropriateness of this routine is established, exercise sessions should be h eld every two hours, or as regubrly as possible.
The clinician's iniLial role is to provide reassurance and encourage ment to the paLient that they are performing the appropriate strategies
to regain their function They must isolate the relevant movemenlS which the patienl should be performing and make sure these are being perfmmed correcLly The clinician's role is to gently guide the paLienL Lhrough and beyond the healing process to the point where recovery of funcLion calls for and allows more vigorous measures. The management willl"irst consist of self-treatment procedures and
only in the event that these fail to proVide improvement should procedures that require the assistance of the clinician be added. At times, i [ improvements are too slow in coming, patient techni q ues may be supplemented with clinician techniques, but the emphaSiS must always be on what the patient is doing for themselves ('What I'm doing is only
20%, what you're doing is 80%') There is no
guarantee, however, that the addition of clinician procedures will hasten the speed of inlprovements. The clinician will idenLify the direction of functional impainnent and may supplement patient exercises with t ech n i q ues that restore full range of pain-free movement. For instance, in capsular restrictions at the hip, stretching into
d i a l rotation can be difficult for the
me
1137
1381 C H
A PTE
REI G H T
THE HUMAN EXTREMITIES:
MECHANICAL DIAGNOSIS &
THERAPY
patient and clinician assistance may be required. The clinIcian may be required to aid in the reduction of internal derangement Reduction by self-applied procedures is sometimes difficult, and it may be necessary for the clinician to mobilise or manipulate to achieve red uction. The clinician must also i den tify postural forces which, if not removed, may delay recovery following trauma.
Compliance or therapeutic alliance? vVhen self-treatment p rogram mes are discussed, the issue of patient compliance or non-compliance with instructions is often raised. Patients are frequently seen as reluctant followers of
m edi c al
or
physiotherapy advice. Various studies have found that average com plian ce with medication regimes is only found in 50 - 60% of patients, while compliance with physiotherapy programmes was consistently worse at about 40% of patients (Deyo
Factors
1982)
that have been found to be important in non-compliance with exercise regimes are the barriers that patients perceive or encounter to d oing the regime, the lack of positive feedback and the degree of perceived helplessness (Sluijs et al.
1993)
Other factors that have consistently
appeared to influence non-compliance are patients who hav e an external health locus of control, complex regimes, regimes lhat are not tailored to the patient'S daily routine, unclear explanations, and lack of explanation concerning the reason for p e r fo r m i n g the programme (SluiJs et al.
1993)
However, it is s u gges t e d lhat as
compliance is defined as the extent to which patienLs adhere to health advice, it implies coercion or passive submission. An alternative has
been proposed, termed therapeutic alliance, which implies negotiation and shared decision-making (Brady
1998)
In ongoing disease states it is proposed that active patient involvement rather than passive submission to health instructions is the most appropriate model "The pass i v e sick role is
i n c o n g ru e n t with
rheumatology findings that control belief s such as se lf-e ff icacy and helplessness are important inJ1 uences on health o u tcom e s
1998).
"
(Brady
Patients and health care p ro v ide r s are each partially
knowledgeable and appropriate decisions can only be made with the active participation of the patient in the deCiSion-making process. Clinicians must inform the patient about the condi t i on and self management strategies, but can only evaluate the effectiveness of
PATIENT MANAGEMENT
CHAI'TER EIGHT
those strategies 'vvith the patien t In turn the patient with a chronic .
,
pmblem has certain responsibilities, Lhese bei ng to: •
learn about the condition and its management take responsibility (or self-management and j oint decision making evaluate the health care experience.
Active self-management rather than c ompl iance is the preferred
OUlcorne (Brady
1998) This can only be achieved if the patient is
su f icie n t ly in fonned and empowered It is the clinician's responsibility r
lO try to creale Lhis state of mind.
To treat or not to treat? Irrespective o f the nature of the problem, whether post-traumatic, non-traumatic, inflammatory or degenerative, it should never be ass u me d that ([ealment by physiotherapy is always necessary There can be no Justification
for applyi ng physical treatment unless that
treatment is known to accelerate the natural histo ry or will assist in the recovery of fun c tion There is no evidence that many com monl y .
used physiotherapy modalities actua lly
do this (Clarke 1999; F e ine
and Lund 1997; van der Windt et al. 1999) H oweve r, the patient must always be gi v en comprehenSive guidance and education in the app rop r iate strategies to assist with the healing process an d to regain
normal funcLion. All patients are entitled to that guid ance and any educaLional tools that may be rel ev ant to their problem Not to do so is to de ny to patie n ts the right to self-manage
their p roblem which,
g i ve n the phYSIOlogical and psychological aspects of th e pain ex perience outlined earlier in the book, may lead to less than optimum treatment and can engender iatrogenic disability All clinicians should be o b liged LO p ro v ide the relevant information to secure the maximum
response in the manner best suited to the pa t ien t s phYSical, social '
and financial w e l l bein g Treatment is
u s u a ll
y perceived as doing something to patien ts -
patients m ay feel cheated if something is not 'done to them', and c l i nicians find it difficult to resist the
e to use hands o n techniques
u rg
'
'
or make use of some modal ity These influences are espeCially strong
in a climate of financial e x change The evidence previously presented
1139
I
140 C,iArTER EIGHT
THE HU,v\AN EXTREMITIES: MECHANICAL DIAGNOSIS
& TllERAPY
makes clear that the value of these interventions is largely un p roven However, it is clear that many patients want to be inforrned about their con dit ion and what they can do about it In physiological terms, regularly repeated movements strengthen and
n ormalise healing tissue and restore to normal function tissue that is abnormal, over-sensitised or de-conditioned. Only p a ti e nts can do these exercises. In psychological terms, patients' in volv eme nt in treatment has the abi li ty to decrease fear-avoidance behaviour a nd allow patients to have greater control over their problem. Optimum treatment of many musculoskeletal conditions is I ou n cl e d on patient '
involvement. Thus the first and rnost powerful management option that should be used is educational It is not always necessary to do so mething to the patient; this should only occur if ot her routes have been exhausted. Treatment can and should always comprise the provision or advice, ini'ormation, encouragement and monitoring of patienL -managed progress At the first interview, and mainly from the patient's history,
we
can
usu a lly ide nti fy whether or not the patient will require education or treatment, or a combination of both. Key factors in t h is decision making relate to the s tage and status of the p a ti e n t s condition It is '
i mpo rtant to know the likely state of the tissue - whether inilamed, healing or abnormal- and whether things are improving, unchanging or worsening.
Condition improving When the patient r e p o rts that their condition is improving,
a
review
of the problem and its prognosis is all that is required. Avoid the inclination to embark on a programme of passive therapies. \Vhatever the origin of the symptoms, whether inflammatory, degenerative or post-traumatic, improvement in the patient's condition is the ultimate aim of treatment. if that pt oce ss is already under way, continuing aL -
a steady rate, and accompanied
at the same time
by improvement
in
function, there is no justification (or any intervention other than ed ucation and assurance. Provide guidelines for the progr e ssion of activity and exercise where necessary, but such patients do not require attending
a
clinic for regular 'treatment'.
An example could
be shoulder pain, which commenced following
lifting or reaching, and is improving [rom the elate of onset. Where
PATIENT MANAGEMENT
CHAPTER E IG liT
that is the case Lreatment is unnecessary. Instru c ti on to tem porarily ,
avoid the painful move me nts and ed u cation to prevenL loss of fu nction
through a graduaLed exercise programme will su ffi ce
in the
management of the p ro blem . A tele p hon e call in a few days should be made to determine if a further consultation is necessary There is as
ye L no evidence Lhat ph ysi ca l treatment accelerates the time
requi red for recovery from such minor problems
Condition unchanging Where the patient reports that a slow insidious onset of pain with moven,ent has developed over time and is now unchanging, a routine approach to the assessment can p roceed and educat i o n and instrucLion for a s u s p e cted dysfunction can be prov i d ed immediately. A similar
routine ap proach can be adopted 'v\lhere the p at i ent reports
only partial bUL st a b l e recovery following a sudden or trau mat ic onset of pain in the past A dys fu n c ti o n resulting from imperfect repair might be suspecLed. Whatever the ty pe of onset stab l e and pe r sistent ,
sympLoms generally suggest the need for a reasonably vi go ro us approach to assessment and management
If the patient describes that sy mptoms res ulting from trauma two to three weeks ago are unchanged s in ce onset, it could mean that heali ng
has nOL occurred or is su ffering fre quent d isrup tion It is uncommon .
but not impossible for h eal ing to take l o n ge r than three or four weeks, especial1>' if the patient is ov e rac ti v e and di s rup ts the process of repair
Athletes and s port s p eo p l e are fre q uentl y guilty of returnin g prematur el), to full ac ti v i t y. If applied too soon after inJUlY, movement
may further delay repair On the ot h er hand, if the commencement of active m o v e m e nt is unduly d e layed, the stimulus to repair that is provided by early movement does not occur. M a nagemen t must take account of the need to re a c h the ri gh t balance between relative tem po ra ry r e st and ac t i v e
,
grad ua ted move m e n t in sub ac u te -
problems Derangement may cause p ai n and function a l impairment that may continue unJbated lor weeks until reduction occurs spontaneously as a result 01
a
chJnce event or is red u ce d by m a ni pulat ion Unlike
pain from the i nn a mm a to ry process, certain repeated m ovemen ts or sustained positions
will reduce t he pain when derangement
is
cJL1sative. T h is will be cla rifi ed after the m echan i cal assessment.
Derangement lTWy be the cause of persistent pain of recent onset
1141
1421 CHArTER
EIGHT
THE HUMAN EXTREMITIES:
MECHANICAL
DI/\GNOSIS & THERAPY
- sub-acute conditions are not always the producL of chemical pain states. If the patient repons pain that has persisted for many months, which may be constant or intermittent, and classification according to one of the mechanical syndromes is unclear, then a chronic pain syndrome
may be suspected Getting such patients started on regular, graduated exercise programmes frequently leads to an improvement in symptoms, function and patient's perceived self-efficacy Initially they may experience an exaggeration in symptorns due to the nature of chronicity, which is likely to involve sensitisation of certain tissues. They should be encouraged to pace their activities, not do too much too soon, and alternate activity with rest. Unless findings emerge from the assessment process that suggest further tests or more caution is required, education and instruction in (l vigorous se I (-Lreatrnent program me are indica Led
Clinician intervention (lL Lh is poi nt is
unnecessary but may [olloyv at a later date should self-treatment and guidance fail to provide improvement Chronic tendon conditions with relatively stable symptoms can represent a failed attempt at repair which has got 'stuck' at some stage. An initially vigorous management approach can provoke symptoms by stressing the tissue to re-stimulate the healing process The temporary aggravation of symptoms should only last (l day or two, and once provoked a more gentle and graduated approach should replace the v·igorous exercise programme.
Condition worsening In the event that the patient d escribes that his or her symptoms are
worsening since onset, it will be necessary to investigate the cause of d eterioration. Should the symptoms be localised and of recent onset, it may be that inadequate avoidance of the causaLive actlvity is all that has worsened the condition. Certain innammatory diseases, including 'frozen shoulder' in its early stage, can progress over time, gradually causing increasingly severe pain. Therefore the possibility of the presence of an underlying inflammatory or more seriOLlS disease process should always be considered. If the patient has been or looks unwell, or if the reactions to mechanical evaluation are atypical or iF they fail to affect the symptoms, the patient should be referred for fu rther investigation
Appropriate blood tests or rad iological
PATI E N T MA N A G E M E N T
C H A I 'T l ll
assess m e n t may s h e d l i gh t o n t he or igi n o f the s y m p t oms i n such
c a se s
.
A ra t h e r g e n t l e a p p ro a c h to t h e me c ha ni c al e valu a t i o n i s alw a ys re q u i r e d If the p a ti e n t d e s c r i b e s t h a t their pain is p ro g ressi v e ly in c re a s i n g . I n c r e a s i n g p a i n i n tensity c o u l d i n d i ca t e t h a t e a r l y nlov e m e n t is not i m med i a te ly app ropria te U nder these ci rc u m stances a purely e d u c a t i on a l appro a c h m a y be indic a te d
,
certa mly for the
fi rst 2 4 to 48 ho u rs P a t i e n t s w h o se s y m p tom s are w o rsening s h o u l d be seen o n a regu l a r
b a s i s u n til s t ab i l i t y o r i mp ro ve me n t occurs , o r u n ti l i t b ec o me s o b v i o u s t h a t re fe rral fo r fu rth e r inv e s tigat ion is necessary. Certain c o n d i ti o n s s u ch as e a rl y s t age ' fro zen should er' may be agg r a va te d by e v e n ge n t l e attem p ts to begin to rega i n fu nc ti on . Such p a t i e m s c a n be a d v ised on re l a t i v e re s t , use of a nalgeSiCS or N SA IDs , and
t h en re v ie wed a t a later d a te .
Co n c l u s i o n s fo l l owi ng it
a n a na lys i s o f
the hi s to ry a n d the m echa nic al assessme n t ,
w il l b e possib l e to c l a ss i fy t h e p a t i e m in to a t l e a s t one o f the
ca tego r i e s o u tl i ne d b e low. Most p a t i en ts will fit a sin gle cate g ory,
a l th o u g h s o m e may d es crib e s y m p tom s of m o re than one syn d r o me [ t is poss i b le fo r the pa ti e n t in te r mi ttem l y to experi ence p o s tu ra l syntp L O m s re s u l t i ng fro m pro longe d l oad ing and at the same t i m e to e x pe ri e nce co n s t a n t pain fro m internal d e ra n g e men t A p a tiem who
has t h e ra i se d sensi tivuy to normal movemen t associa te d wi th chro nic pa i n may also have an u n d e rlyi ng m e c hani c al response to movements . From t h a t c l assification i t shou l d be poss ible to dete rmine the re q ui re d ma nage m e m p ro gra m me fo r t h e p a ti e n t o r to refe r h i m o r h e r to a m o re a p p ro p r i ate source of c a re in th e eve n t that t h e c o n d i t i on is unsu i t e d to the m e c h a n i c a l appro a c h . It sh o u ld also be possible at this stage to d e c i d e wh e t h e r or not the p a t i e n t is l i k e l y L O re q u i re c l i n i c i a n i n t e r v e n t i o n or a p u re l y
e d u ca tiona l a n d sel f tre a tm e n t p rogramme . The p r ogr a mme d e tails -
s h o u l d b e p rov id e d in wri t i n g to i m p ro ve co m p li.a n ce . This is espeC I a ll y i m portant if t he re is any doubt regard i n g the pa tients ability Lo c o m p reh e n d and co m p ly with i t .
E l li J-l l 1 1 43
1 44
1 C H A PTE R
EIGHT
T H E H U M A N E X T R E M I T I E S : M E C H A N I CA L D I A G N O S I S
& TI-l E RA rY
The pat ient must [i t one of the following clas s i fi cat ions : Table
8.1
Tissue
s tate
C l as s i fication
chart Managem e n t strategy
t rauma/i nflammatory
re s t
hea ling
re s t o ra t i v e e x e rc ise p rogra mme
pos t u ra l s t ress
re - e d ucale
a r ticu l a r dys fu n c t i on
re m o d e l e n d - ra n ge
museu I o t e n d onous d y s fu nc t i o n
re m o d e l t h ro u g h ra n ge
a r ti c u l a r dera nge ment
reduce
c h ro n i c p a i n s t a te
rec o nd i l i o n a n d dese n s i l i se .
9: Management and Self Treatment
Introduction Previous cnapters have described tne various pathological states that the tissues may be in during different stages of a musculoskeletal disorder Conditions are continuums tnat present with different tissue states at diFferent stages of the disorder A traumatic or insidious onset unleashes an inflammatory response. Tnis is l"allowed by the healing and remodelling processes, which if incomplete may leave tissues that are abnormal, dysfunctional, deconditioned or sensitised. Obviously management that is appropriate at one stage will be completely inappropriate at another. Patients may present with pain behaviours Lhat are appropriate for an acute problem, while the same behaviours in someone with chronic pain is inappropriate and maladaptive Treatment required to reduce an articular derangement "vill differ from th a t needed to remodel a dysfunction. A straight I'orward postural syndrome patient who fails to correct persistent poor posture ancl/or faulty technique in manual or clerical labour rnay cause his or her problem to progress so that it becomes no longer reversible will, a simple correction of posture. Thus management strategies are determined more by the stage or nature of the disorder rather t han the structural diagnosis. The status of the condition,
whether it is improving, unchanging or worsening, is also an important determinant of management decisions. This chapter proVides the general principles by which different stages of a condition ancl different disorders need to be managed. It should always be remembered that it is not simply disordered tissue states
LhaL are being treated, but individuals with various anxieties, fears, misconceptions or inappropriate behavioural responses to their pain(ul condition. At every stage of a disorder patients need to be provided with the relevant information to allow them to manage the problem eHectively Tneir questions need answering and any worries or fears that they have about the pain need to be addressed. This is an integral part of ensuring optimal management of their condition.
CHAPTER
N INE
1145
1461 CHAPTER. N IN E
THE HUMAN EXTR.EMITIES: MECHANICAL DIAGNOSIS &TIIERAPY
This chapter contains general principles on the management and treatment of: postural syndrome tissue injury (acute) tissue healing (sub-acute) articular dysfunction (chronic) musculotendonous dysfunction (chronic) derangement syndrome (acute through to chronic) chronic pain states. This chapter also briefly considers the role of clinician techniques and passive modalities in the treatment of musculoskelelal problems as these are so widely used. The philosophy behind this approach is finnly committed to patient education and involvement in treatment: these interventions detract from this. However, al times there may be a role for additional clinician forces, although this should never be done as a first option. In terms of passive modalities there is both very little evidence to support their use, and such treatment, based on a passive recipient role for the patient, undermines the message that confers prime importance on self-management
Normal tissues, abnormal stresses - Postural Sy n dro m e Pain occurring in the extremities as a result of prolonged postural or
positional loading is common. Individuals will report lhat a fle r
a
period ol time they experience nredness or aching in the limb. The longer the position is maintained the worse the pain becomes Relief is usually obtained immediately by a mere change of position or by moving the affected muscles. During the early stages of the symptoms, discomFort or pain ceases entirely once the offending position is changed. Education aL this stage while the symptoms are purely postural would probably avert the more disabling stages from developing. It is in this phase that education is most effective, although few receive it. With continued prolonged or re petitive loading over many months without adequate rest periods and/or relaxation, micro-trauma may result and an inOammatory response is triggered which is not amenable to
MANAGEMENT AND SELF-TREATMENT
av o idance t echn iqu es
.
Cumulative trauma rath e r than a dis crete
traumatic event thus bring about pa thol ogical ch anges (Smith 1996;
Thorson and Szabo 1992; Yassi 1997) The needl'or the prov i si on of appropriate w o r k stations for keyboard o pe r a to rs and o t he r s performing s t a t i ona ry tasks is now well
re c ogn i sed Employers h ave an obligation to provide e mp loyees with .
ergonomically d es i gned workstations that minimise postural loading.
There is an oblig a tio n on the part of the employee to us e the workstation in the manner required for efficient op e ra t i on The bes t ergonomically d es igne d chairs and d esk s are of no use if the emp l oyee
sits slouched at the key board The correction of the workin g posture .
is the s ole responsibility of the employee. Education abou t the importance of posture and i n t erru pti o n of sustained wo r k i n g
p os i t i o n s should be provided. If the patient reports that pain only arises under conditions of static
l o adi n g, and if
movement is painless and symptoms cannot be
prov oked ,\lith active resisted or en d-range p assive overpressure, ,
the pro b lern is postural This can be confirmed by apply i ng a prolonged l oad i ng asses s ment
.
Educa tion towards se lf-m a n age m e n t
The p at ient should b e given a n e xplanation of the cause of the pain and how self-care involves frequ e n t i n te rrupti o n and break s [rom
the repetitive or s u stain ed activity, if they are no t able to avoid the task completely Frequent interruption of the causative position or
posture is e ssen t ial to prevent the condition from worsening. Repetitive full-range movement of the affected structures achieves this, if cl o ne very re gul arly - every haH-hour for one minute. Regular
IS-minute breaks from keyb oard work have been recommended, lor i ntens ive work e ve ry hour and for ordinary work every two ho urs
- rotation of Job tasks is a more efflcient solution (Huskisson 1992) Infrequen t exercises would app ear to h ave no effect upon workers'
symptoms
For i nstanc e
,
two seven-minute on-the-Job e xerci se
routines performed each s hif t for a year prod uced no signific ant diffe re nce i n d i s com f o rt compar e d to those not partiCipating
(Silverstein
et
al. 1988)
Overall b ody posture sh oul d be altered re g u l ar l y and be well supported lr work is being perfor med in constrained or ine fficient postures, patients need to be in forme d how to attain and maintain a
CHAPTER NINE
1147
1481 CHArTER
NINE
THE HUMAN
EXTREMIT I ES:
MECHANICAL DIAGNOSIS & THERM'Y
better working position. They should be warned especially about sustaining abnormal or extreme Joint positions
Ergonomic
interventions, which are considered to be important in the prevention and treatment of repetitive strain injuries, seek to reduce the repetition of tasks, t heir abnormal mechanical stresses and vibration, and improve working postures However, as the physical environment improves, work organisation and psychosocial factors become more important and also need to be addressed (Yassi 1997) The possible implications of continuing 'vvith the same occupational stresses should be made clear to the patient Self- treatment procedures required
The patient must be shown how to modify or avoid the causative posture Teaching the patient to reduce or stop their pain simply by modifying their working posture is an essential step in the prevention of further problems. Duplicating the offending pOSition or posture until pain is provoked best does this Once symptoms have appeared, have the patient change posture or, if necessary, perform appropriate movements until the pain goes. For example,
a
typist may develop
pain in the upper arm after several hours of typing Such symptoms are common and frequently result [rom sitting at the keyboard for prolonged periods in too low a chair. This requires the upper arm or the forearm to be raised in order to operate the keyboard. Raising
[he height of the seat is usually sufricient to allow the upper arrn to hang limply by the side with the elbow at a right angle This will relieve the static loading of the muscles involved Most sLlch problems are r esponsive to postural or positional modification of the workstation. Encourage people to think that posture is
a
habit that
can be changed over a few weeks if the necessary consciousness is maintained-like all habits it can be changed, but sincere elrort must be made. In certain situations, however, Lt is irnpossible to alter the physical
environment suffiCiently to avoid pain Under these circumstances, patients must be taught repeatedly to move the affected structures through a full range of Oexion or extension for about
a
minute every
half an hour. Dynamic postural stresses have a role in the onset and aggravation of various musculoskeletal problems such as anterior knee pain, tennis elbow, supraspinatus, carpal tunnel syndrorne, elc. These faclors will
be mentioned in the next chapter
in the appropriaLe secLions.
MANi\GEMENT AND SELF-TREATMENT
Acute presentations
Traumatic onset - tissue injury FirsL aid measures following trauma wil1 vary depending on the
severity of the injury Se rious injuries thal require hospitalisation are beyond the scope of this book It is nonetheless necessary for all those involved in the later management of the patient to familiarise themselves with the extent of the mjuries and the nature of Lhe immediate post-traumatic care. Where injuries warrant emergency interventions, iL will be impractical to commence immediate physiotherapy or rehabilitation. Nevertheless, orthopaedic physio
therapy may sooner or later be required to recover function and rehabilitate the injured In the event Lhat the extent of the injUry did not require hospitalisation bUL the Lrauma was still considerable, the chance of a fracture or dislocation should be born in mind. This is especially pertinent following impact il1Juries such as during contact spons or motor vehicle accidents, and in certain groups such as young children or older women wILen Lrivial evenLs can produce disproportionate injury Thorough radiographic examination is the best way LO rule out such eventualiLies. A proLocol [or selecting patients with injured extremities
who nlay need x-ray examination has been developed. The set of criteria tlLat best discriminated those with fractures or dislocations were bone ddormiLy, instability or crepitus, point tenderness, ecchymOSis
or
severe swelling in the upper limb, and moderate or
severe pain in the thigh with weight-bearing (Brand et aL 1982) TlLis text considers soft tissue injuries only, in which any more serious damage lLas been properly discounted Management
Shortly after trauma the innammatory process will commence. The tissue damage causes a release of chemicals, one effect of which is to increase capillary permeability This causes localised swelling from innammatory e x u da t e , which develops within a few hours immediate swelling is a sign of substantial bleeding The exudate is rich in protein, including l"ibrinogen; from this will come a network of fibrin tnaL \vil l hold the wound edges together. However, excessive amounts of exudate, and thus fibrin, promotes large quantities of scar tissue which will be a problem later. At this very early stage the csc;ential aspects of management are protection from further damage ancllimitation of funlLer bleeding or swelling This is achieved using
C H A PTE R Nt N E
1149
150
I CHAPTER
NI�I
THE
HlHvlAN EXTREMJTIES:
MECHANICAL DIAGNOSIS & THERAPY
the basic formula of Rest Ice Compression Elevation (RICE). Gentle muscle contractions may also be useful to promote venous dramage (Evans 19 80; Hardy 1989; Enwemeka 1989) Recent evidence-based gUidelines have been produced by the Association of Chartered PhYSiotherapists in Sports Medicine in the UK which endorse the general rest, ice, compression and elevation model, but also include protection of the injured area (ACPSM 1998)
It is recommended
that these guidelines be used by all 'in the immediate (up to 72 hours) post-injury management'. There is no indication from the evidence for the use of ultrasound; this will be addressed in detaillaLer in the chapter For the first few days following injury it is best not LO commence the process of recovering function. The inflammatory phase lasts about five days during which Lime the RICE regime with gentle movements should be pursued. Protection of the wound from further damage, which might maintain this phase or cause more exudaLe, and limitation of the swelling are still the main points of management Animal experiments have shown Lhat follOWing
injury
two days' rest
is insufficient and causes further damage and increased quantities of abnormal scar tissue. Five days' rest allows the newly formed granulation tissue to cover the damaged area and to gain sullicient strength to withstand the subsequent mobilisation. Longer rest than this promoted weak and abnormal scar tissue, which was contracLed and of poor structural organisation (Lehto et al 1985; Jarvinen and Lehto 1993)
'vVithin the first week gentle movenlents must be
commenced to start to influence the quality of repair and stimulate circulation. Exact timing to SLan mobilisation will depend upon the extent of the injury and be determined by pain response to gentle movements
Treat Your Own Strains, Sprains and Bruises (lindsay
el
al. 1994)
provides an excellent self-management programme [or the immediate and later guidance of the patient in his or her own home This book also shows patients how to progress injury rehabilitation over the first three weeks Where attendance at an outpatient clinic is sought, management during the first week following injury remains the same and the RICE strategy plus early mobilisation should follow routinel y Some injuries may require temporary immobilisation, but this should be used as sparingly as possible and be interjected with some regular movement, however limited.
MANAGEMENT AND
CHM'TER
SELF-TREATMENT
Sub-acute presentations Post-trauma - tissue healing
From about the fifth day following trauma, fibroblasts proliferate
and collagen is laid down, with maximal d e p osit ion occur ring by about three weeks The strength of the wound in cre ases but is still
far from normal. An animal experiment found t b at skin wounds at sixty days were only ten to fifteen per cent of control
v
al u es, an d
even at 100 d a ys were only about one-third the strength of intact skin ( D o u g l as eL al. 1969) Mobi!ising thus proceeds grad u ally, bUL
never so that aching is aggravated or worsened. By the third or fourth week after injury cross-links between collagen fibres begin to increase the tensile strength of the repair tissue. It is essential during this reparative phase of the healing process that careful tension is applied
to the wound, but well within the patient's tolerance of discomfort. The te n s ion encourages the correct orientation of the new collagen
so that it aligns along the line of stress of that structure, and thus
p roduces the best functional outcome. If tension is not applied to healing tissue, the new collagen is laid down randomly in a way that lacks tensile strength, is prone to developing adhesions, contractures, and excessive cross-links between collagen fibres, therefore hindering function As the weeks pass the degree of tension applied should be in c re as e d in a p rog re ssive manner ('Nitte and Barbul 1997; Evans 1980; Hunter 1994; Hardy 1989; Enwemeka 1989) From about the third week collage n synthesis is matche d by collagen l y si s so the quantity of collagen is no longer on the increase. Cross
link age between collagen fibres continues the process of strengthening the repair tissue. The same n e e d to a pp ly tensile and contractile loa ding to the healing tissues applies as before. This prevents the
fomlation of restraints to normal [unction a nd encourages the strength of structures appropriate to
full range
n
eed . During the remodelling phase,
of m ov e m e nt and tensile and contractile loading as well as
functional capabilities should incrementally return to normal levels.
The ten d en cy for wound contracture to occur, and therefore the need to continue to stretch the area long after healing, must be conveyed to the patient (Evans 1980; Hunter 1994) Educa tion towards s elf-managem e n t
The patient sh oul d b e given a clear explanation regarding the overall steps that they need to take to manage and rehabilitate their problem to full function and pain-free status. This may include some
NII'iE
1151
1521 C
1-1 Ar TE R N I N E
THE HUMAN EXTREMITIES: MECHANICAL DIAGNOSIS & TI-IEI"\AI'Y
i n formation a b out the healin g process that their injury is going
through, and t he risk of l as ting impairment if the app ro pria te rehabilita tive process is not p e rformed They sh o ul d understand that c o mplete rest of the injured part i s necessary for only the f i rst Few days, if that. Gentle a t t empts a t m ovemen t should he made at some t i me every day as early as possi b le Instruction in ITlOvemenL and .
exercise should commence as soon as possible depending upon the patien t s condition and pain. Both the number and frequency of '
repeated movements and the anti cipaled progression required for
recovery should be ex p l a in ed P a tients must be g iven a clear model of ac c eptable pain behaviour
H
pain is p ro duc ed by movement but abales when the movement s t o p s or decreases upon repetition, this is acce p ta b le. If pain, which is prod uced durin g movement, remains worse afterwards or if pain progreSSively i n creases with repetition, this is not acceptable at t h is a c ute stage With the latter res p onse mobilisation is applied e i t h e r
too soon or too vigorously and needs to be m o di fied See Chapter S e ven for a more detailed d escript ion of sy mpt om atic and mechanical responses to l oading .
It should be stressed here that this cautious approach to encouraging patient activity is only ap pro priate at this earl y sta ge when prevention of further dama ge is a relevant management goal. \Vhile exaggerated pain behaviour at thiS stage allows the individual t o aid recovery and p rot ect from excess vi gour Just a few weeks laler the same pain ,
behaviour is inappropriate, maladaptive a nd liable t o cause increased pain and d isability Self- treatment procedures
The patient should understand that initially the number or
m ove men ts their frequency and the range should be gui ded by pain ,
res p o n se The patient sho u ld attain as full a r ange of movement as .
pain allows. The number and frequency or m oveme nts will vary, but a minimum goal of five movements every two hours should be set
and m o re often if pain permits Both the number of movements and .
the ran ge achieved should progress daily As a m ea ns of progreSSion to i m pr ov e b o th stren gt h and fun c tion all patie nts should be taught ,
self-resisted m ove me n ts These can be commenced once pa in fron1 .
resis tance can be tolerated.
MANAGeMENT AND
SELF-TREATMENT
CHAPTER
For different injuries and parts of the body different programmes
will be required. Most physiotherapists are well aware of the r a nge of exercises needed to make the appropr iate progressions. Progressions may involve any or the following factors: non-weight bearing/weight-bearing; inner range/outer range movements; isometriclisotonic loading; concentric/eccentric loading; and velocity of movements. Some examples of different progressions are shown below
I
PI)otos I, 2
Early /lo/l-weight-bearing ac/il'e mOl'ement into jiJ//olI'ing if /{(/emllig{//nent s/)rain oj tlJe ankle.
the
discomfort
zone,
in this case
2
Photos j, 4 Later weight-hearing actil'e ankle.
.3
l1Iol'ement jollowing
4
a latera/ligament sprain oj (IJe
NINE
1 153
1541
CHAP TER NINE
THE HUMAN EXTREMITIES: MECHANICAL DIAGNOSIS & THEICAI'Y
Photos 5, 6 "ccentric loading of Acbilles' tendon during lale slage reiJabilitation of a chron Ic probleln, The affected leg (bere tbe right) starts il1 plal/tarjlexion and unloaded. The weigiJt is transferred to tbat leg Clnd the beellowered to provide eccentric loading
More vigorous exercise is important in the prevention of dysfunction or structural impairment, especially in patients undertaking demanding sporting, recreational
or
occupa
tional activities. Exercises should relate to the individual patient's functional demands Where Significant disability or weakness persists, resisted strengthening exercises with gymnasium equipment may be needed once pain and range of motion permit
Chronic presentations The majority of patients seen by physiotherapists are not in the early stages followmg trauma. What nas been explored so far is the straightforward rehabilitation of a soft tissue injury with the optimal, appropriately timed management Unfortunately patients are not often like this; of course this is why they are seeking treatment They are not getting better - pain has remained and function is still limited. Those who recovered in a linear fashion and are where they want to be functionally do not seek treatment Those we see are always 5
likely to be the more 'difficult cases' where the normal healing process has not gone th rough all it s st ages due to inappropriate, over-protective behaviours, failure to remodel. pre-existing degeneration in the tissues, sensitisation caused by malfunction in the central nervous system, or [or Oiome other reason the condition has become 'stuck' dur ing the process of repair. As shown in the introduction, many common musculoskeletal conditions that are frequently seen by physiotherapists nave long and persistent histories. Late traumatic presentations - abnormal tissue
Patients may present with persistent pain long after a reasonable time for the normal healing process. In patients who present long after trauma, healing will probably have occurred without the benefits of education or advice. Where this has happened it is frequently the case tnat clysfunction exists. Such patients may seek assistance for persisting pain G
ancl limitation of movement. Late insidious onset presentations - abnormal tissue
Patients who present with pain of insidious onset can go through the same tissue responses as those follOWing trauma - inllammatlon,
CHAPTER
MANAGEMEI'-JT AND SElr-TREATMENT
repair and remodelling - or they can also become 'stuck' at one of these stages 'Frozen shoulder', 'tennis elbow' or osteoarthritis of the
hip or knee, for e xa m ple
,
can be seen at different t im e s as an
innammatory or l1i echa ni cal disorder. Tendon disorders in particular
are prone to l engthy, protracted and abo rted recovery. The insid i o us onset is likely to i n d i ca te pre-existing o veruse or degeneration which
has undermined the ca p ab ili t y of t h e tissue to heal norm a ll y (Leadbetter 1992; Buckwalter
al. 1993) Because of th is the
et
t imefra m e for such p roblems is ge nerally much longer. D esp ite their weakened s tate , it is imp ortant to remember that all c on nective tissue need l oa d i ng stresses in o rd e r to improve function. Intra-articular derangements
Alternatively, foll owing a t ra u ma ti c or n on tra uma tic onset patients -
may have persistent symptoms and lim itation of normal fun c tion
because of intra-articular derangements. Chronic pain states - abnormal tissue
I abnormal response
An o the r scenario is that tissue h e alin g may be co m ple t e
,
but
sensitisation to normal movement or fear of pain may be p reven ti ng
the individual from regaining full [u n c ti o n . With pain that has persisted for l ong peri od s iL is important to recognise the role that neuronal plasti ci ty and/or psychosocial [actors can have in m o dul ating
pam se n s a t i on irrespective of the lo cal tissue state. Chronic musculoskeleLal pain has been shown to be maintained by pathological sensitisation in pe riphera l and central nervous systems -
a state where the d y sfu n ction al tissue is neur a l rather than somatic
(Cohen 1996) Patients' fear of pa in beliefs about pai n, or feelings of ,
lack or cont rol may all be factors that maintain an ongoing pain state. In p at ien ts
with p ersist ing musculoskeletal pain, the role of non
mechanical factors should a lw ay s be considered. In s umm a r y these different forms of tissue a bn o rm ality may be ,
pre sent in condi tio n s thac have persisted after the nonnal re cov ery pe rio d These equate to: .
somatic tissue dy s function
-
-
a r ti cul a r c o n tractil e
intra-articular derangement
neural tissue malfunction / ina pp rop riate pain behaviour. The m a n a ge men t of these pr ob l e m s will be reviewed in the following sections.
NINE
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C H A I'T E R N I N E
T H E H U M A N E X T R E M I T I E S : M E C H A N I CA L D I A G N O S I S & T H E RA P Y
A bnormal tiss ue, normal s tresses - Dysfunction Syndrome
Dysfunction in the e x t remities co m monly affe c ts e i t he r a r t i c u la r o r m u s cu l o t e n c1 o nous s t r u c t u res . C o n trac L i o n o r a d h e re n c e o r s O lt tissues is a very fre q u e n t reas o n for l oss o l l"u n c t io n . T h i s a b n o r mal, shortene d tiss u e m a y h a ve arisen fro rn a p a s t t ra u nl a t i c eve n t or be t h e pro d u c t of a n overuse or degen e ra t ive cond i t io n . N o rma l s t lTsses re p r o d u c e the p a tien t 's p a i n
R e m o d e l h n g o f these s t r u c t u r a l l y
i m paired tissues o c c u rs ove r m a n y wee ks a n d m o n t hs . S t r uc t u ra l i m p a i rm e n t c a n n o L b e ra p i d l y n o r m a l i s e d . A s l o w b u t g r a d u a l i m p r o v e m e n t mu s t b e e x p e c t e d
T h e re fo re , i rr e s p e c t i v e o f L h e
t re a tm e n t p rovid e d , l i t t l e change in pain i n Le n s i t y o r range o f mo t ion i s s e e n f r o m d a y t o d a y in t h e m a n a ge m e n t o r p a t i e n t s w i t h dys fu n ctio n . The re i s a h i g h l y c h a ra c t e ris t ic sy m p t o m a t i c res p o nse t o loading s t rate g i e s i n d y s fu n c t io na l t i s su e . The p e r f o r m a nc e o[ re p e a t e d moveme n t s i n the di recti o n t h a t p ro d u c e s loa d i n g o f structura l ly i m p a i re d , c o n t ra c te d , a d h e re n t , fi b rosed o r a d a p t i ve l y s h o r t e n e d s t r u c t u res w i l l p ro d u ce p a i n . Re p e t i tion o f t h e rn ov e rn e nt d o e s not make the p a i n progressi v e l y wo rse . Range of m O L i o n will n e i t h e r be increased nor re d u ce d . 'vVhe n the limb o r S L r u c t u re is re t u rne d to the n eu t ra l p o s i t i o n the pain will cease . The pain that t h e pa L i e n t c o m p l a ins o f w i l l b e re p roduced b y e n d - range s t ret c h i n a rt ic u l a r d y s fu n c ti o n a n d t h ro u gh range c o n t r a c t i o n i n musc u l o t e n d o n o u s d ys fu n c t io n . The t e s t m o v e m e n t s m o s t c o m m o n l y re q u i re d fo r assessing J o i n t a n d a dj acent s o ft L issue [u n c t i o n a re Il e x i o n a n d e x t ens i o n . R o t a ti o n m ay b e re q u i r e d fo r t h e s h o u l d e r a n d h i p . Ho wever, a l l j o i n t movements shou l d b e assess e d LO d e t e rmine the
fu ll range o f m o t i o n a n d the m o s t s a l i e n t re s p o n se s G e n e ra l l y s p e a k i n g , t h e m o v e me n t s t h a t p ro d u c e t h e gre a t e s t a m o u n t o f mechanical de fo r m a t i o n a n d t h e refore p a i n c a n , whe n m u d i l i e d a p prop riate ly, b e used to have the g reatest t h e ra pe u t i c elTe c l . A rticular dys function
A r t i c u la r d y s fu n c t i o n may p res e nt w i th a h i s t o ry o f t ra u m a o r i nsi d i o u s onse t . Pa tients w i th articul a r dysfu n c t i o n re s u l t i ng from an o l d inj u ry will h ave rep o r t e d in t h e ir h is t o ry t h a t they have had
the sy m p t oms fo r seve ra l months . The sy m p t o m s dale back t o some e v e n t or in j u r y t h a t has n e v e r c o m pl e t e l y re so l ve d . I n i t i a l l y t h e symp toms were m o re seve re o r more n o ticeable a n d h a v e i m p ro ve d , b u t are persisting and n o i m p rove m e n t h a s o c c u rre d [o r s o m e t i m e . The re will be restri c t i o n o f movement o f the a ffe c L e d J o i nt a n d p a i n
M A N /\ G F M E N T ;\ N D S E L F - T R E A T M E N T
w i ll
comm
e nc e if' m o v e m e n t towa rds t h e res t ri c t i o n i s a c t i v e ly o r
pass i ve ly p e r fo rm e d . D e ge n e ra t i v e
j oint
d i s e a s e c a n c a u s e a d a p t i v e c h a n ge s w h i c h
e v e n t u a ll y im p a c t on t h e j o i n t c a p su l e a n d s u r ro u n d i n g so ft t issu e s .
T h i s i n t u r n c a u s e s c o n t ra c t i o n o f t h e c a p s u le a n d r e su l t s i n p r ogres s i v e l oss o r m o veme n t ; t h u s osteoarthri tis is a l s o co m m o nl y
L he c a u s e of a r t i cu l a r dys func tion . Anoth e r cause o f i n s i di o u s o n s e t a rt i c u l a r d y sfu n c L i o n i s l ate-stage ca p su li t is o f t h e gleno-humera l j oi n t . A ft e r t h e i n i t i a l i n n a m ma t o r y stage the ca psu le can b e l e ft with seve re
loss o f m o v e m e n t , bu t pain a t e n d - r an ge o n ly I f the s u b l e c t 's p a i n is p ro d u ced at a c t ive e n d - ra nge movement that is l i m i t e d , and not through the a rc of m o v e m e nt , the p r obl e m i s p r o b a b l y ca p s u la r. I f t h e p a in i s p r od u c e d o n l y a t p a s s i v e b u t
mecha n i ca l ly l i m i t e d e n d - ra n ge a n d n o t t h rough the a rc o f movemen t , t h e problem is p roba b l y c a p su l a r. I f o n l y o v e rp r e ssu re a t end - range is p a i n [ u l , the p ro b lem i s p ro b a b l y c a p s u la r . If a n th r ee tests a re
p a i n ful , the p ro b l e m is c a p s u la r dys fu n c t io n . Thi s w i l l be confi rm e d a fl e r a p p l y i ng re s i s te d m o ve m e n t s , n o n e o f w h i c h c a u se p a i n . Re p e a te d e n d - range m o v e m e nt s w i l l c o n fi r m this. Th e y w i l l , each
ti m e , re p roduce the p a ti e n t 's p ai n , w h ich get neither be tte r nor worse , b u t a h ,\te 'vv i t h i n
m i n u te s o f c ea sin g the movements .
The loss o f fu n c L i o n o c c u r r i n g
in t h e j o in t s o f the e x t remities is
I're q u e m l y in the s agi t ta l p la n e . As is most c o m mo n in th e hu m an s p i na l col u m n , e X Lension is frequently re d u c e d a t the e lb o w, wris t ,
fi n ge rs , h i p , knee a n d an k le Flexion m a y be red u c e d a t t h e s h o u l d e r, e l b o w, w r i s t , h i p , k n e e a n d a n k l e j o i n t s . L o s s o f ro t a t i o n a n d
a bd u c t i o n is a p a rti c u lar prob lem a t t h e shou l d e r a n d h i p T h u s i t is L h e case t h a L t h e p ro c e d u res require d depend on the pa r t i c u l a r move me n t l osses o b s e r v e d at tha L i n d i vidual j O i n t . In the case of a rt i c u l a r d ysfun c ti on , re m o d el l i n g o f the involved s t ru c tu res will r e q u i re rep e a t e d m o ve me n t l o a d in g s u ffi c ie n t t o re p roduce t h e p a t i e n t 's pa i n a t en d - r ange . Educa tion towards s elf-manage m e n t
I t is v e r y im p o rtant to g i v e the p a tie n t a tho ro u gh e x pl an a t i o n o f the c a u s e of the t i ss u e a b n o rm a l i ty, t h e r e a s o n fo r t h e n e c e s s a r y
m a nage ment and the e xpec t e d p r ogn os i s . Patients will be p rese n t i n g
with p a i n a n d a b n o rmal fu n c t i o n ; thei r c h ie f com p lai n t is u s u a l l y
C H A P TE R N I N E
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TH E
H U M A N EXT RE M I T I E S :
M E C H A N I CA L
D I AG N O S I S
& T H E P,A I'Y
pain They are only likely to t o le r a t e a manage ment strate gy t hat i n v o l ve s produ c in g tha t p a i n at r e gu l ar in terva l s i f they are gi v e n a
c o n v i n c i n g re a s o n fo r s u c h a c o u r se o f ac t i o n. A de sc rip t i o n o f t h e h e aling pr o c ess and possible stru c t u ra l im pe r fec t i o n s t ha t may o c c u r d uring this pro cess u s i ng the exam p l e o f c o n t racte d sca r t i ssue sh o u l d
be gi ven. The cap abili t y of tissu e to be rem o d e l le d by re peated s t resses and th e sel f- t reatment p r o c e d u res needed to re m o d e l sho u l d be expla i n ed . A tirne fra m e fo r rec overy s h o u l d b e p ro v i d e d . T h e c o nd it i o n wi ll n o t c h a n ge q u i c k l y
for some time
-
-
e s p e c i a l l y i [ i t has been presen t
and they must be warned not to be ove r-o p timistic
about t he t ime need e d for impro v e m e n t Re m o d e ll i n g of tiss u e t a k e s
weeks or m o nt hs o f regu l a r r e p e a t e d m o v e m e n ts
-
the p a t i e n t 's
committed input is v i t a l fo r rec o ve ry f o r only the p a t i e n t c a n p e r fo rm ,
the a p p ro p r iate exercises with e n o u gh f requency T h e patient must be warned or the need to s tre ss s t r u c t u res t o t he point o f pai n , but n o t to t he p o int o f d a m a ge a n d lasting p a i n By
sho wing t h e m that pain , al th o ugh eas i l y a n d consi ste n t ly p ro d u ce d , aba tes wi thin min u tes o f ceas ing t he stre s s fu l man o e u vre , t he pa t ie n t is p ro v i d ed w ith a s imple exa m p le o f p a i n behaviour to fol l o w Ve ry o ften in d y sfunc ti o n the cl inici a n s main ro le is t o ensu re that the appr o p ria t e exercises and p ro g ressions a re b e i ng done c o r re c t l y and
with e n o u gh reg u lar ity, to make su re that the patient u n dersta nds the e xpec t ed p a i n resp o nse , a n d t o pro v ide e nc o u rage m e n t a n d m o n it o ri ng o f t h e p r o g r e s s i n s y m p t o m a t i c a n d m e c h a n i c a l
presen ta tions . The pati e n t sh o u ld b e revie w e d i n t w o d ay s a nd a t the en d o f t h e first week t o co r rect and check exercise t e c h n i q u e s
,
regu lari t y, pain resp onses and the patie n t 'S u n d e rs t a n d ing o f t he c o n c ep t o f dy s func t i o n A p p ropriate progre s s i o ns o f resisted e x e rc i s e s
or m o d i fi e d t ec hni qu es s hould be added as i n d i c a t e d . S ubse q u e n t rev i e\Ns can frequently be c o ndu c t e d over t he tele p h one o n a w e e k ly basis or w i t h irregular visits to t h e clinic Self- tre a tment p rocedures re quired t o re model a rtic ula r dys fun ction
When the d i a gn os i s of d y s fu n c t i o n has b e e n ma d e i n a n i c u [ a r
stru c tu res i t follows t hat t reatment d e s ign e d to re m o d e l ,
af
fec t ed s o ft
t i ss u e s is i n d ic a t e d To e n s u re that a re m o dell i ng p rocess can b e i n itiated success fully, i t is frequently necessa ry to a p p l y s u ffi c ient
stress t o the a ffected str u ctu res to s tim u la t e the fo r m a t i o n o f b e t te r quali ty c o l l a g e n re pa i r o r scar tissue
M/\ N A G E M E N T I\ I" D S E L F - T R EA T M E N T
C H APTE R N I N E
e x a m p l e s o r e n d - r a n ge s e l f- m o b i l i s a l i o ns fo r use
in
a r ti cu l a r
d y s fu n c t i o n PblJ/o 7 m/a/io ll oj the '"i) witb ll 'ifholl i ope/pressure.
t'vIedilll
or
Photos 8, 9, J 0 iffe rent ways oj acbieuil1gJlexion oj the bil) with oue/jJress u re. The me/bod with the stolJ/ mcl), be easier tlJ do in tbe work en l'iro n m e l l t.
D
7
8
l)
10
1 1 59
1 60
I C H A rn R
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T H E H U M A N E X T R E M I T I E S : M E C H A N I C A L D I A G N OS I S & T I- I E RA I'Y
Phntos J I , 12, 13 Diffe rent ways of achieving hip exle nsin n, bilatemlly n r u n ila tel'Ctl/)J (left hip only). The meth()d ill. ph()to 13 IIItI)' succeed in prnducing pain at end-range that is not provoked by the other procedure_
12
II
Phntos J 4, 15 Knee extension, susta ined
or witIJ
interm ittent
Dve/pressure.
14 15
C H MT E R
A N D S E L F - T R E ATM E N T
M A N AG E M E NT
I n the case o f a rticular d ys fu n c t i o n , t he pa t i en t m u s t b e Instru cted a c t i ve l y to mo v e t h e a ffected j o in t towa rd s t he restricti o n until p a in is fe l t The m o v e m e nt s h o u ld be re peated ten or twelve t i m e s to the p o i nt o f p a i n , th ree or fou r t i m e s d a ily If t h i s is d o n e w i t h o u t exace rba ti o n o f s y m p t o ms the e x e rc i s e s h o uld b e in c r ea s e d t o e very ,
two hours . A ft e r the fi rs t wee k o r ten da y s the p a ti e n t sho uld be ,
s h o wn how t o p rog r ess to s e l f a ppl y ove rpress u re using the he a l th y -
a n n o r l e g . In manY Joi n ts i t is only t he ad d i t i o n o f o v e r p ressure t h a t
wi l l g e t t h e J o i n t to e n d - range . F o r instance , full h i p a n d k n e e flexion i s i m p o ss i b l e to obta i n by a c ti v e movement on l y Ov erp r ess ur e may s o m eti m e s be ne cessary fr o m day o n e .
The a p p ro pria t e
e x e rc i
s e s shou ld be continued u n t i l fu n c t i on and
p a i n a re i m p ro v e d . Frequ e n t l y the m o v e m e n t w i l l i mp r o v e as sy m p t o m s d o T h i s is not a lways t h e case , however ; sometimes the r e s tr i c t i o n IS l i t t l e c h a n g e d , b u t s y m p t o m s i m p r o v e move m e nts a re
e
When
s p e ci a l ly s ti ff wi. t h a hard end - fee l , the abil i ty to
rem o d e l th e t i ss u e and I mp ro v e sy m p t o m s is m u ch less , and fail u re to h e l p Lhis g ro u p is high . After an improvement in p a in and function,
e xe rcises p e r fo rm e d as on e session e a c h day s hould help to maintain t h e i mp rove me n t s t h a t h a v e b e e n ac hie v ed i m p o r t a nt i n
-
this i s esp ecia l ly
de gene rative j o i n t co ndit i o ns
Musculotendonous or con tractile dys function
The pa tien t ma)' describe e i t h e r a t ra u ma t i c or i n s i d i o u s o n s e t . T here may be , for instanc e , a h lst o r y of a g ro i n or c a l f strain , or t h e y may
de scribe l o n g-term symp toms o f rep e t it i v e o r cumulative s t ra i n such as fro m a te n n i s elbow o r ro ta t o r c u ff disorder. Any i n fl am ma t o ry diso rd e r o f te n d o n or s hea th also has t h e c a pacity to cause l a st i ng i m p a i rm e n t 0 1 the a ffe c t e d s tructu re s . S y mpt o m s w i ll have been
p resen t [o r sev e ral mon ths , b u t would initially have been more severe .
T he
c
o n d i t i o n h a s i mp ro v e d , b u t p e rs i s t e d wi th n o fu r t h e r
i m p r o v e men t
.
Resisted m id - range move m e n t p ro v o k e s the symptoms 1 £ t h e p a i n
i s p rovo ked b y resisted movemen t a p pl i e d at a n y p o i nt in t h e arc s h ort o f e n d - ra nge , t he problem m u s t a rise fro m one or more of the c o n tra c t i le s t r u c tures . Mid - range rep e a t e d and or resisted mo ve me n ts are ind icated. The c o n t ractil e s tructure h a s to fu l fill two func tions i t mu s t be a b l e t o c o n trac t and wo rk against l o a d ,
-
b u t i t m ust also be
ab l e to s t r e t c h i ts fu l l l e ngt h ( F y fe and Stanish 1 992) Mus c u lo te ncl o n o us dys fu n c tion a l tissue is painfu l on resisted moveme nts and
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E X T RJ M I T I E S : M I U I A N I C A L D I A G N O S I S & T H E RA PY
i f the flexibility o f the u n i t is teste d If the c o n tracti le s t r u c t u r e can be s t re tched , this also provokes disco m fo rL and i s restricted c o m p a re d t o the o ther l i mb . F o r instance , dys fu nc t i o n o f t h e Ac hilles' t e ndon will b e sy m p t o m a ti c when p u s hi n g u p onLO the toes a n d w h e n pa ssivel y s t re tching i n t o d o rs i flexion Remo d e l l ing is requ ired where a ten d o n has become a d h e re n t to its s h e a t h , w h e re excess ive cross linkage of c o l l a gen re p a i r w i thi n the c o n t rac t i l e s t ru c t u re has o c c u rre d , o r where fi brosis has deve l o p ed fo l l o w i ng reso l u t i o n of haema t o m a . I f pain o c curs midway through any moveme n t , i t c o u l d a r i se [ro m either d e ra ngement w i th in t h e j o i n t or fro m muscu l o t e n d o n o u s dysfunction - the cause n e e d s t o be d i fferen t i a te d . Passi ve m o veme n t will provoke t h e sy m p t o ms i f they a rise fro m in t e rn a l derangement and w i ll b e pain less i n c o n t rac tile dys fu n c ti o n . Resisted m o v e m e nts applied in the ' t a rge t z o ne' w i l l provoke the s y m p L o ms i f Lhey a rise fro m t h e t e n d o n or mus c l e , b u t w i l l gene ra l l y b e p a i n l e s s i n derangement Repeated resisted mi d - ra nge moveme n t s a re i n d ic a te d . As i s t h e c a s e w i t h a r t i c u l a r d y s fu n c t i o n , m u s c u l o t e n d o n o u s d ys function will requi re re pea ted move m e n t l o a d i n g su ffic i e n t t o repro d u ce t h e p a tien t'S p a in ; u n l i k e art i c u l a r d ys fu n c t io n , t h i s is u s u ally re qu ired shon of end - ra nge . Educa tio n to wa rds self-management
See Education towards s e lf-manag e m e n t secti o n ab ove u n d e r a rt i cu l a r d ysfu n c t i o n . Self- treatmen t procedures re quired to rem odel m usculotendonous dys function
In the case o f muscul o t e n d o n o u s dys functio n , t h e m o v e ment t h a t causes the gre a test amou n t o f pain a ls o provides the gre a test s t i m u l us o r i rr i ta t i o n to the a ffe c t e d tiss u e s . T his will readily be fo und b y testing o u t tho se moveme n ts descri b e d by the pat i e n t as being pa i n l1.1 1 ,
if necessary 'vvi th resistance . One o f these \vil! c o n s i s t e ntly provoke the pa tien t's pain . H a v ing id entified the most p a i n ful move m e nL , i L is then ne cessary to fin d the po int in the range whe re resisted e xe rcises s h o u l d first be applied . St atic or d ynamic l o a d ing may be used to re mode l muscu l o te ncl o no u s d y s fu n c t i o n . E x e r c i s e s s h o u l d gene r a l l y b e p e r fo rm e d w i t h o u t a p p ly ing s o m u c h l o a d ing that there i s a risk o f c a u s i ng damage or disru p tion t o t h e re m o d e l l i n g process and re- t r i ggering a co nstant i n fl a mmatory p a i n . The m o d e l of p a i n beha v i o u r is Lha t pain is
M A N AG E M E N T AN D
S E L F- T R.EATM E N T
C H A I 'T E K N I N E
p ro d u c ed by t he r es i s te d exercise , b u t a ba te s once the loa d i ng ceases . The exerc ise p ro gr am me
com m e nces wh e re the l o a d mg is su ffi cient
to ge nerate t he p at i e n t s pa i n , but ceases when
Photos 1 6, 1 7, 1 8 Finding tbe target zo ne. In this case it is at the sbo ulder Tbe patient exercises in mid-range, througb the {lrc oj greatest pain. IJpain is too severe, exercises s/Jort 0/ the tmget zo ne sbo uld be carried o u t.
the l o a d i n g is re m o ve d . T here is an exce p tion to this ge nera l ru le i n the case of certain chronic t e n d o n p r o b l e ms t h a t a re a s s o c i a t e d w i t h degenera t i ve chan g e s ; t h i s wi l l be d isc u sse d later
F o r t h e s e c o n d i ti o n s a t e m p o ra r y
aggrav a t i o n o f s y m p t o m s i s s o m e t i mes necessary t o re - s t i m u l a te the he a ling process . T he p o i nt i n t h e a rc of m o vemen t tha t pro v o kes p a i n o r whe re p ain is a t i ts maxim u m is a re lia b l e g u i d e 'vv h e n d e C i d i ng 'vv h e re i n the ra n ge i t is best t o a p p ly l o ad ing for the p u rpose
16
o f re mo d e l l i ng . T h i s is t h e ' ta rge t z o ne ' fo r the p a t i e n t's focu s . if the p ain is fe l t at the s a me i n t e n s i t y t h ro u g h o u t t h e r a n ge i t i s n o t
necessary t o s e e k a ' t a rge t z o ne ' . H a ving identified th e p o i n t d ur i n g the p a i nful movern e n t the p a t i e n t s h o u l d th e n be sh own t h e p roced mes tha t
w il l
a pp l y e i t h e r s t a t i c o r
d y n a m i c l o a d i n g s u ffi c i e n t t o c a u s e repro d u c tion o f t he p a i n
.
The a p p ro p r ia teness o f
t hese p roce d u re s s h o u ld b e estab lished over a
17
test p e riod and p rogressions given as necessary O p t i o ns a v a i l a b l e i n c l u d e a c tive m o v e ments , s t a t i c re s is t e d m o v e m e n ts a n d con centric a n d ecce n t r i c l o a d i ng E x e rcises can b e pe r fo rme d i n o u te r ra n g e , i n n e r r a n g e , sho rt o f the 'targe t z o n e ' a n d in the ' t a rge t z o n e ' i ts e l f. E c c e n t r i c l o a d i n g i n p a rt i c u l a r h a s b e e n sh o wn to be e xtre mely
u se
fu l
i n t h e rehabil i
t a t i o n 0 1 c h ro n ic tend o n p ro b l e m s (Alfredson
et a f . 1989 ; F y fe and S ta ni s h 1 9 9 2 , S tanish et al. 1 9 8 6 ) S t a n ish re p o rts
an
et
al. ( 1986) for ins tance
18
unc o n t rol led s t u dy of 2 0 0 p a t ie nts
w i t h c h ro n i c t e n d o n p ro b l e ms w i t h marked res t rictl0ns o f t h e i r ,
n o rma l lu n c l i o n a n d fal l u re to r e s p o n d t o a v a r i e t y o f phys l o t h e ra p y
1 1 63
1 641
C H A P TE R N I N E
T H E H U M A N E X T R E ,v\ I T I E S : M E C H A N I C A L D I A G N O S I S & T I- I E R A r' Y
Photos 7 9, 2 0
Finding the targe t zo ne a l lbe
,,!Jo t/ldel; i l l
abducl ioll
and
ro lalioll in I/)is case.
Variation oj flJe position oj fbe a rt iculalion al any joinl lIlay 1)(' lIi!cessarv 10 jind
the best target zO lle.
19
20
2 1 , 22, 23, 24, 25 target zo ne a l lhe sboulder when pail l is similar Ib m l/g h o u l 'he 11101 '1' 1 I1I ! 1 I 1 . Exercises are pe'ljonned tiJro llf!,iJ Jull ra nge and shn i/a r/v Ior all 1I I0l 'elllel ils {I I oll:Jer jOin ls. In this case, lo-u'-grade eccen tric [o{/dinp. is (Icbie/ 'ed by /ou 'ering {be arm to tbe side.
Photos No
21
22
M A N A G E M E N T A N D S E L F-T IUAT M E N T
C H A I 'T E R
24
25
p rogra rrnn e s a n d c o r t icost eroid inj e c tio n s . F o l l o w i n g an e c c e n t r i c st rengt h - l ra in i ng p rogram m e p e r fo r m e d daily o v e r a s i x - w e e k peri o d , p a t i e nt s we re fo l l o w e d up fo r a n a v erage of sixteen m o n t hs . F o r 44% o f palien ts t h e re was c o mple te re lief o f sy m p toms and re t u r n to normal fu n c t i o n , 4 3 % had a mark e d decrease in the problem (mild aching afte r sporting a c t i v i L i es) , 9% w e re unchange d , and only
2%
we re wo rse .
Low -gra de e c c e n t r i c l o a d i n g c a n be achieved w i th a c t i v e m o v e me n ts a l one , fo r i nsta n c e a t t he sho u l d e r in lowering the arm to the sid e . The
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weight o f t he limb can be s u p p lem e n ted by a we igh t i n t he hand . I f a t the shoulder a c t iv e exercises a r e i nhib i ted by p a i n , t h e sta rting p o si t i o n can b e changed [0 supine l y i n g , wh ich u s u a l l y p e r m i ts i mproved mob ility N o t eve ry indiv i d u a l w i l l have t o go t hro ugh a ll t h e p ro g r e s s i o n s m e n t i o n e d . N e c e s s a r y s t a r t i n g p o i n t s a n d progressi ons a re d e termi n e d in Il1 d ividu a l cases by symp t o ma t ic and mechani c a l res p o nses Isom e t ric con t ractions exert less tension th an d yna m ic c o n t ract i o n s , a n d t h u s m i g h t b e appro p ri a te fo r i n i t i a l u s e i f there i s c o n c e r n a b o u t the stability o f the s tage of healing ( F yfe a n d Stanish 1 99 2 ) However, isometric co n tract ions can i n duce hyp oxia in t h e con t ra c t i ng m u sc l e w i thin m i nutes, so it is re comme n d e d t hey be h e l d fo r a m inimal length of time ( S o l omono w and D ' A m b ro s i a
1 9 87)
Static load ing
can be used where the s a m e pain i n tens i ty is e xp e r i e n c e d in all pa rts o f the range of movemen t In this cas e , appl ying t e n s i o n w i t h o u t mo vement u s u ally p rovo kes t h e p a i n . S t a t i c l o a d ing can b e a p p l i e d at d i ffe l-e nt angles to evalu a te w h e re the b e s t resp o n se is ga i n e d . T h e p a tient m u s t be taugh t t o a p p l y the righ t a mo u nt o f re s i s t a n c e t o p revent moveme n t bur to ca use some p a i n . The pain s ho u l d b e pro v o k e d b rie n y, t e n t o fi ft e e n t i m e s i n e a c h s e s s i o n , re l a x i n g co mple tely a fter e a c h co ntraction , and re peated t h ree
or
[ou r times
a
day If the response to th is is accep t a b l e the fre quency sh ou ld be i n c re a s e d to e v e ry two o r three h o u rs . Isometric e xe rc i s e s o n l y i n crease strength at the j o i n t angle at whi c h resistance is a p p lied (N o rris
1 9 93) ,
the re fo re dyna m i c e x erci ses may b e necessa ry t o
p r o g re s s t r e a t m e n t . I f p a i n i s e q u a l t h ro u g h o u t t h e r a n g e o f move ment , l o a d i ng can a lso be d o n e t h rough the e n t i re ra nge D ynamic loading is p re ferable when a ' targe t z o n e ' is i d e nti lied - i n w h i c h case l o a d i n g is carried ou t t h rough t h e pain fu l a rc . App rop ria t e s t i mu l a tion is b e s t obtained by i n i t i a l l y a p p l y i ng l o w a m p l i t u d e a l t e rna ting concen tric a n d e c c e n t r i c rn i n imal loading te n to fi ftee n t i m e s . T h e amp litude o f c o n c e n t ric a n d ecce n t r i c load i n g as w e l l a s t h e d e gree and s p e e d o f l o a d ing can be i n c re a s e d o r de c r e a s e d a c c o rding t o t h e p a t ien t 'S p a i n respo n ses (Fyfe and S t a n is h 1 9 9 2 ) A fter ini t i ally tes ting o u t the resp onse wh en t he e x e rc ise i s a p p li e d three o r fo ur times a day, t he se ries s h o u l d then b e re pealed e ve ry two hour s .
C H A PT E R N I N E
M A N A C; E M E N T A N D S U F - T R EATM E N T
In l h e e v e n t t h a l
a
s l ow b U l s te a d y i m pr o v e
m e n t is made , no change needs to be made to
the manage m en t a t t h is time . S h o ul d pain from l o a d i n g l e v e l s gra d u a l l y red u c e , it m a y b e
n e cessar y to i n c rease l o a d i n g p rogressive ly to
Pbotos 26, 2 7 C()mpression du ring actilie lYlol'emen t. in tbis case fo r lateral ep ico ndylitis. Tbe patient fir mly (/pplies pressu re to the painfuL extensor origin witb fbI' tbumb or index finger reinforced by tbe m iddle fingel: The wrist is tben extended and rela.xed ten limes el'elT tu'!) bours.
p ro v i d e the n e c e ssa r y s t i m u l u s fo r rem o d e l l ing. I f s t re ngt h e n i n g is nee d e d fo r a spec i fic tas k , s po r t i n g o r occ u patio nal , the n the exercise must m i m ic that task as c losely as pOSSible ; t h i s is i n line w i t h the s p e c i ficity o f strenglh t ra i n i ng
( No r r i s 1 9 93) Eccen t ri c l oa d i n g in p a r t i c u l a r h as b e e n I- o u n d t o
acc e
l e r a t e re c o v e r y a n d
l w s l c n s t re n g t h ga i ns , a n d h a s b e e n shown t o be very va l u ab le in t h e re habi l i tation o f chro nic te ndon p robl e nls that h a v e fa i l e d t o i m p ro v e w i lh o the r t re a tm e n t s (Al fre dson e t a l . 1 9 89) . Howeve r, i t is m o re fa tiguing than conc e ntric
26
w o r k a n el m o r e p ro n e t o i nd u c e m u s c l e sore n e ss ( F y le a nd S tanish 1 9 9 2 ; N orris 1 993)
I n t h e e v e nt t h a t t h e p a t i e n t h a s i n c re a s e d
sy m p t o m s
at fo l l ow- u p ,
il w i l l be n e c e s s a ry t o
rev i e w t he e x e rcise a n d t h e e ffec t s on pain I t m a y be l h a t t h e p a tie n t h a s inc reased p a in o n ly fo r
a
short time a fl e r exerc i Sing, in vvhich case
Lh e re c o m m e n d e d exe rcis e s sh o u l d b e c o n t i n u e d lo r
a
fu n h e r two o r t h r e e d a y s .
H o w e v e r, s h o u l d t h e p a t i e n t have in c re as e d
pain wh i c h re m a ins w o r se l o n g a fte r exerci se ,
27
the rec o m m e n d e d p rogra mme s h ou ld be mo d i fie d . M o d i fication o f the p rogra m m e m a y ta ke several fo rms Th e first o p t i o n s h o u l d b e to exerc ise in the leasL p a i n fu l range , i f on e can b e fo u n d . This may i nvo l ve sta t i c h o ld s well away fro m the t a rge t zone ' . Alt e rnati vely, in '
some c ases it m a y be necessary t o exercise in a n o n p a i n f u l range as -
c l ose l y adpce n t as poss ible to the poim whe re pain commence s . I f
e x e rc i s e i n this fo rm c a u s e s n o i n c re a s e i n p a i n , the mo d i Fi e d p r o g r a m m e s h o u l d con t i n u e fo r a fu r t h e r t e n t o fo u r teen days . A l te rnative l y, c h anging t h e starting po s i t i o n c a n h e l p - for instance , v a r i o u s s h o u l d e r e x e rc i s e s , w h i c h may be impossib le or a ggrava ting in s t a n d i n g
,
can b e cl one with ease when lying
1 1 67
168 1 C f I A I' T E Fl
NIN E
T H E H U M A N E X T R E M I T I E S : M E C H A N I CA L D I A G N O S I S & T I HltA I'Y
S h o u l d no i mprov e me n t fo l l ow a fte r two to t h ree weeks it may be necessary to increase the degree o f load i ng t e mp o ra r i l y to i rr i t a te t h e tissue . This is more likely t o be nece ssa ry i n c h ro n i c Le ndon p ro b l em s which have b e e n stable over time and that arise in de ge n e r a te d L i ss u e . T h is occurs silent l y
III
man y i nd i v i d u a l s a n d i s l i k e l y w h e n t h e r e has
bee n a n insid ious onset o f symptoms The b r i e f pe ri o d of s L i m u l a t i o n o f the t i s s u e s serves t h e p u rpose o f re- trigge r ing t h e h e a l ing p ro c e ss which a p p e a rs to be absent o r s u s p e n d e d w i t h t h e re pa i r p rocess ,
' s tuck' . A ft e r an i ni t i a l provo c a ti o n , w h i ch w o rs e ns the c o nd i t i on fo r a day or two and gen erates c h ange , l oad ing needs to be re d u ce d . To restimu late the tiss u e increased l o a d ing is re q u i red fo r ins t a nce b y ,
w o r k i n g i n t h e t a rge t z o n e o r w i t h t h e a d d i t i o n o f w e i g h t s . Alterna tively, increased s t i m u lu s c a n b e o b ta i n e d d u ring t h e e x e rcise by app lying p ress u re loca lly aga i ns t t h e p a i n fu l reg i o n using t h e finge rs o f t h e hea l thy l i mb . Wh i le the patie n t acti ve l y p e r fo r m s the movemen t , he or she a p p lies s t a ti c o v e r p re ss u re or com p re ssion a t the si te o f max imum tend e rness . O n c e these proced u res have s t i r re d u p t h e condit i o n so t h a L constant a c h i n g has been achieve d , the increased load i n g s lLoLd d be s to p ped The a c hing should only last a day o r LWO , [o l l o w i ng w h i c h a c t iv e range o f movem e n t , a n d l a t e r resiste d , exe rc ises sho u l d be i n i tiaLed t o re h.a b i l i t a te the s t ru c t u re . I f thes e m e a s u re s la i l t o p r o v i d e i m p rovem e n t , t he p a t ient s h o u l d be instru c te d to s t o p al l p rovoca t i v e lo a d ing fo r fo u r t o five days . S o me ti mes a pe rio d o f re l a L i ve re S L a ft e r th e stimu lus o f exe rc is e exposes a n i m p r o v i ng s L a t u s . Tre a tm e n t
S h o u l d a pu re l y s e l f- manage m e n t p ro t oc o ) fa i l t o p ro d u c e s o m e i m p rovement wi thin a fou r-week per i o d a re view o fthe ma n age ment ,
p rogra m m e sh o u ld be c o n s i dered . I f compliance w i t b exe rc is i n g has b e e n l e s s t h a n requ i re d , a tt e m p ts must b e made to see k b e t t e r co o peration fro m t h e p a tient I f co mp li a nc e w it h exe rcise has b e e n
ade q uate , the a d d i t i o n o f m o re v ig o r o u s ge n er a l a C l i vi ty a n d o r e xercise is indicated and c l i nici a n p roc e d u r e s i n t h e fo rm o f res i s t e d e c c e n t r i c e xercise m a y b e i n di c a t e d . A fu l l y e q u i p p e d m o d e r n gymnasiu m i s a ne cessary a dj u nc t to t h e re h a b i l i tati o n and p h ys i c a l rea c tiva tion o f ce rtain pati e n ts w i t h m u s c u l oskeletal d isa b il i t y a n d impairment, e spec i all y w h e n t h e p a t i e n t is req u ired t o e xe r t m o re than a ve ra ge fo rces t h rough the m u s c l e beca u se o C occ u paLional o r s p o rting a c ti v i t i e s . Attendance a t a gy mnas i u m w here s p e c i alised e q u i p m e n t is ava ilable must a lwa ys be c o n s i d e re d .
M A N A G F M E N T A N D S U. F - T R E A T M E N T
0-1 A P TE R N 1 N I '
I n t h e e v e nt t h a t t h e p a t i e n t h a s c o m p l i e d with a l l i ns t r u c t i o ns rega rd ing e x e rc ise a n d remains u n i m p ro v e d , it is so m e t i m es the c as e t h a t t h e re c e n t i n c re a se d a c t i v i ty is s u f fi c i e n t t o s t i m u l a te t h e remo d e l ling p rocess w it h o u t t h e p a tien t n e c e ssa r il y b e i n g a w a re o f the ch a n g e s occu rring Whe n co n d i tio n s h a v e g o t ' s t u c k ' du ring the re m o d e l l i n g s t a ge th e s t i m ul u s o f d irec t t i ssue l o a d i ng , such as working i n t h e ' t a rge t zone ' , may o fte n b e su m c i e n t t o i n i tia t e further cha n ge F o l l o w i ng this t he s ti m u l a tion of the exercise needs t o be s t oppe d fo r a p e r i o d of re - a ssess men t . A cessa t i o n of all p resc ribe d e x e rc ise i s s o m e times su ffici e n t fo r the p a t i e n t to re co g n is e that i m p rov e m e m is i n d eed o c c u r r i n g C o nsidera t i o n s h o u l d be give n to i n s t ru c t ing t h e p a t ient to use t he l imb as normal for u p to two weeks Tn s o m e c o n t ra c t il e c o n d i tions s trap pi n g may be co n s i d e r e d as a
s u p p l e m e n t to t h e m a n agement o u t l i n e d above
Some i n di v i d ua ls
w i t h p e r s i s te n t ten n is e l b o w p ro blems , fo r i ns ta n ce , are a b l e t o p e r fo r m Lhe i r n o r ma l s p o r t ing o r r e c r ea t i ona l p u r s u i t s p ro vi d e d they
use
a
s u i ta b l e stra p . A trial pe r i od may b e n e c essary, as these i t ems
w i l l n o t he l p eve ryone . Articular Dera ngem e n t Syndrome It is c o m m o n
fo r i n terna l d e r a n ge m e nt t o occu r qui t e su d d e n l y in
the J o i nt s of t h e eXLre m i t ies . This is unlike internal d e ra n g e ment a flec Ling t he c e rvica l a nd l u m b a r i n terverte b ral d i scs w h e re a slow grad u a l o n s e L over s e ve r a l cl ays o r weeks is commo n . The re a so n for
t h i s may be t h e abse n ce o f n u c l e a r gel i n the j o i n t s o f the e x t re mi t i es . The m e nisc i of the k n ee a n d t e m p e ro - m a ndib u l a r J o int a re k n o wn to
L e a r a n d c a use l o c k i n g or o bs t ru c t i o n to m o v e me n t . P a i n fu l
o b s t ru c ti o n t o m o v e m e n t o r p a i n i n the m i d -ran g e o f mov e me n t wit h o u L o b s t ruction is a fea t u re 0 1· de ra n ge m e n t occu rring in the j oi n ts o f t h e e x tr e m i t i e s . L o o s e b o d i e s fro m d e ge ne r a t i o n o f a rticu l a r carti lage a n d bony fragme n t s have been fo und at s u rg e ry w i thin t h e
knee , e l b o w, s h o uld e r and h i p J oi n ts . Osteochond ri tis d i ss e ca n s a t t h e knee o r e l bow c a n p ro d u c e i n tra - a rt i c u l a r b o d i es t h a t r es tri c t full movement (Pa L L e n
1 99 5 )
I mpingeme n t of s y no vi a l membrane may
a lso be a c a u se o f o b s tr u c t i o n to j o i n t mo tio n . Tea rs and c a t c h ing o f the a ce t a b u l a r l a b r u m a t the h i p c a n p ro d u c e p a i n ful episo d e s when twi s ti ng o r moving ( F i t zgera ld
1 99 5 ) W h a te v e r the
t r u e ca u se s may
b e , i nt e r n a l d e r a n ge men t of the extre m i ty j o i n t s o c c u rs a n d i n some
c a s e s r e c u rs fre q u e n t l y. T h e r e wil l g e n e r a l l y b e a r a p i d o n s e t p ro d u c i n g a p a i n fu l li mit a t io n t o certa i n m o v e m e n t s a t a
j oi n t .
1 1 69
I
1 70 C H A PT E R N I N E
T H E H U M A N EXT R E M I T I E S : M E C H A N I C A L D I A G N O S I S & T l l E RA ry
As r a p i d onset is a c o m m o n ch a racte ristic o l de ra nge men t , it IS a lso
the case that ra pi d red uction o f derangement may be ac hieved . U n like the s l o w i m p r o v e m e n t t h a t o c c u rs w i t h the r e m o d e ll i n g o r d ysfunction , re d u c t i o n o f d e r a nge ment may o c c u r i n two to t h ree weeks o r less . It is therdo re c o m m o n to o bse rve dai l y im p ro v e m e n t
i n levels o f pain a n d i n c reased ra n ge o l m o t i o n as
a re s u l t
o f applying
red u c t iv e l o a d ing fo rces t o the ob s t r u cti o n R a p i d and l a s t i n g c ha nges o c c u r w he n d e range m e n t is t h e cause o f pa i n . S u d d e n o ns e t con stant p a i n m a y the rdo re be the resu l t o f constant
mechan ical ddo rm a l i o n d u e t o a r t i c u la r d e ra nge me n t . C l inici ans should always b e a w a re that c o ns t a n t acute pain i s n o t n e ce s sa li l y d u e t o inflamma t i o n , b u t m a y re s u l t fro m a m e c h a n i c a l d i so rd e r : the sym p t o m re s p o nse shou l d b e clear. A l t h ou g h in de r a n g em e n t some
m o v e m e n t s may c a u s e a w o r s e n i n g , t h e re m a y be d ra m a t i c im p ro v e m e n t s with re p e a t e d movements i n a c e r t a i n d i re c t i o n . The ra p id onset o f pain ful obstru c t i o n t o the atta i n me n t o r e n d - ran ge
m o v em e n t excl u d es the possib i l i t y o f dys fu nc t i on as a d i a gn o sis A n a l t e r n a t ive b u t l e s s c o mmo n p rese n t a t i o n o f d e ra ng e m e n t is pain
p r o du c e d d ur i n g the a rc of a c t i ve m o v e m en t , e s p e c i a l l y i n o n e direc t io n , with en d r a n g e move m e n t pain less a n d n o t o b s t ruc ted . -
In the h is t o ry the patie n t w ill d e s c ribe tha t c e r t a i n rn o v e me n LS c a lise ,
h i s o r her pain to increase , a n d o ther m ove m e n t s w i l l c a u s e the pain to d e crease or stop c o m p le te l y As the pain i n c re a s es
,
movement
becomes m o re d i Fficu l t . T h e c o nv e rse a l so a p p l i e s - as p a i n re d u ces , m ov ement should become easier. If d u ri n g t he mecha n ical assessme n t
p ro cess the patient e x p e riences a n i n c re ase in pain or the p a i n becomes more wi d e s p re a d a w o rsen i n g o f the c o n d i t i o n i s l i ke ly ,
Co nv er se l y i f there is a d e cre ase i n p a i n in te n S i t y o r l o c a l i s a t i o n o f ,
the pain the c o n d i t i o n will be i mpr o v e d b y p ro c e d ures o r m o v e m e n t
rep e a t e d in t h a t d i re c ti o n
In d e r a n ge me n t t h e p e r fo r m a nc e o f ,
re p e a t e d mo ve me n t s i n the direct ion t ha t i nc re a ses p a in w i l l a l m o s t c e rta inly increase the d e ra n gem ent The re is a n in crease in pa i n
inten s i t y and s y m p t o ms w i l l b e c o m e m o re w i des p read , u s u a l l y distally The p e r fo rman ce o f rep e a te d move m e n ts i n t h e o p pOSi te d i re c t ion res u l ts i n a red u c t i o n of t h e deran ge m e n t and re d u c t i o n i n
p ain , ge n e ra l l y o r d i s t a l l y ini tially ; th at is , l o c a l is a t i o n o f t he pa i n to i t s s o u rce . This cha racte ristic o f a d er a n g e m e n t to fa vo u r m o v e m e n t in o n e d irec tion is t e rm e d ' p re fe renoal d i rection'.
M A N AG E M E N T A N D
S E L F- T R E ATM E N T
C H A l'TE r,
A l t h o u g h t h e re i s n o s a t i s fa c t o r y e x p l a n a t io n , s o m e a p p a re n t m u scu l o te n d o no u s p rob lems cause p a ins t ha t respond t o l o ading in
a n i d e n t i c a l m a n n e r to a n i c u l a r d e r a n g e m e n t . The c l i n i c a l presentatio n 0 1 t h e s e p ro blems
IS virtua lly
id e n ti ca l t o c e r t a m s o ft
t i s s u e I n j u r i e s . H o w e v e r , t h e y c a n m a k e r a p i d a n d l a s t in g improveme nts t h a t a re more sugges tive o f a r t i c u l a r d e rangement than
a so fL t i ss u e i nj u r y Certain s ho u l d e r c o n d i t ions , apparently a ffe c ting t he t e n d o ns , can b e c o m e p rogressive l y wo rse when re p e a te d e xtreme e n d - r a n ge lo a d i ng is a p pl ie d in i n ternal ro tati o n . The sym p to ms wi l l re main w o rse u n t U re p e a t e d ext reme e nd - range loa d i ng i s
applied
in
e x te rn a l ro t a t i o n . Al t h o u gh c o nj ec t u ra l , i t is p ossi ble t h a t a fol d i n
L he synovial lin i ng o r t he c a p su l e itsel f c o u l d b e alternately i m p inge d and release d . S i m i l a r instant cha nges o f sym p toms have been observ e d
w i L h a p pare n t
t e nn i s elbo w s a n d lateral l i ga ment s Lrains o f the ankle
(M u l l igan 1 9 9 2 ) W i t h these ' pseu d o ' t e n nis elbows , fo r instanc e , a l a t e ra l glide a t t h e e l b o "v w h i l e the p a ti e n t c o n t r a c t s t h e i r w r i s t e x t e n s o rs m a k e s t h e m o v e m e n t p a in - fr e e ; a ft e r re p e t i t i o n , t h e c ontract i o n rem ains p a i n - fre e . Edu ca tion in self-managem e n t
The n a t ure a n d c a u se o f the p roble m m u s t be expla ine d to t h e p a ti e n t -
t h a t a d i s p l a c e m e n t wit hin the j o i n t i s preventing m o v e m e n t and
c a us i n g pain I t shou l d b e explaine d that this c a n b e made worse by c e r t a i n m o v e me n ts a n d re duced b y o pp o s i t e ones . They s h o u l d te m p o ra r i l y a v o i d the aggra v a ti ng p osi tions a nd mo vements , bu t a t t h e s a m e t i m e regu l a rly d o the re du ctive m o vements . These may c a use s o m e i nc re a s e i n p a i n at the t ime , b u t a fterwards the J oin t shou ld fee l b e t t c r a n d move m e n t s should be e asi e r . The re s h o u l d b e no l a s t i n g aggrava t i o n o f p a in
S y m p t o m a t i c a nd m e c h a n i c a l
p resema t i o n s s h o u l d w o rse n a n d i m p r o v e in t a n d e m . The s e l f re d u c t i ve p ro c e d u r es s h o u l d be d e m o nstrated a n d the n pra ctis e d b y
t h e p a t i e m u nt i l c o rrec t . T h e time fra m e o f a few weeks fo r recove ry sh o u l d be o ffe re d to th e p a t i e n t i f i t a p p e a rs tha t re du c t i ve p ressu res a re b r i nging a b o u t a la s ting c h a n ge i n sym p t o ms and movement .
The i m po rt a n c e o l regu l a rly pe r fo rmin g the ex e rc is e must be made clear t o t he p a t i e n t . This c a n be p e r forme d ten t imes three o r fo u r t i mes d a i l y in th e fi rst few days , a n d t h e n m o r e r e gul ar l y o n c e the p roce d u re and res po nses have b e e n checke d .
T h e p a t i e n t s h o u l d b e rev iewed in a fe w d a ys . I t sh o ul d b e checked whe t he r a n d h o w fre q u e n t ly t h e y have b e e n d o i n g the e x e rcise . The
NINE
1 1 71
1 721
C H A PTE R N I N F
T H E H U M A N E X T R E M I T I E S : M E C H A N I CA L D I A G N O S I S & T H E RA I 'Y
p ro c e d u re sho u l d be che c ke d to e n s u r e it is d o n e c o r r e c t l y, a nd resp o nse t o t h e p r o ce d u re s h ou l d be d e t e r m i ne d . I f t h e y a re d o i ng a s i n s t r u c t e d a n d i m p r o v e m e n t s a re o c c u r r i n g managem e n t s ho u l d c o n ti n u e . A ft e r
a
,
t h e p re s e n t
cou ple o f \ri SltS re v i e w can be
by t e l e p h o n e . Self- trea tme n t procedures required t o reduce in tern a l derangeme n t
In derangemen t , re d u c t i o n o f dis p l ace d tissue w il l requ i re re pea ted e n d - ra nge m o vement l o a d i n g i n the di r e c ti o n t h a t p ro g ress i v e l y re d u c e s pain . I t is u s u a l that a c c o m panyi ng the re duc t i o n o r p a in t here w i l l be a simu l ta ne o u s i m p ro v e m e n t
111
t he ran ge of m o l i o n
as
the obstru c tion i s red u ced . To achieve re d u ction t h e p a t i e n t first a p p lies re p e a t e d active e x e rc ise t o e n d - ra nge . Pro v i d i n g the pain b ec o m es progress i v e l y l e ss w i t h re petiti o n o r the range o f m o vem ent increase s , o r bo t h , t he p a t i e n t m a y c o n t i n u e t h e b asic e x e rcise w i t h o u t mod i fi ca t i o n u n t i l re co ve ry i s c o m p l e te S h o u l d i m p rovement c e a s e , t he fi rst p ro g ressi o n o f se l f a p p l i e d overp ressu re s h o u l d be made . Th e p a t i e n t m u s t be i n s t ru c t e d t o a p p ly t h i s u s i n g t h e hea l thy h a n d i n t h e c a s e o f u p p e r e x t re m ity p ro b l e ms or b o th hands i n the case o f l ow e r e x t re m i ty p ro b l e m s M o re forcefu l o v e r p ressure c a n fre quen tl y b e gain e d u s i n g a n a rt i cle
o f furniture to assi s [ . i f the overp ressu re i s in t h e c o r re c t d irec t i on , t h e e x t r a fo r c e w i l l p r o d u c e m o r e
r
e d u c t i v e p re s s u re ;lI1 d
i m p r o v e m e n ts i n mec hanical and sy mptomatic p rese n t a ti o ns w t l l fo l l o w. In t h e eve n t tha t i m p rovement ceases fo l l O W i ng t h e a p p l i c a t i o n of o v e rp re ssu re , t he p a tient sho u l d be i n s t r u c t e d i n t h e a p p l i ca t ion o f resis t a nce t o w a rd s the direction o f o b s t ru c t i o n . In d e r a n ge me n t i t i s some ti mes t h e c a s e t h a t re sis t e d m o ve m e n t towa rds t h e obstru c ti o n , t h a t is t o wards e n d - r a n g e , results in inc re ased ra n g e a n d d e c r e a sed p a in . Wh e re e n d
-
ra
n g e i s n e i t h e r l irn i t e d n o r p a t n [u l b u t the
d e rangement p resents with an a rc of p a i n , res i s t e d move rne nlS may b e the trea t m e n t of c h o i c e
.
I n l h ese case s , re peated mo v e me nts
,
resis t e d thro u gh the a rc o f p a i n , s h o u l d be a p p l ied fi rst i n the mos t p a i n ful direction . If re peti tion red u ces the i n t e ns l l y o r p a i n , the p a t ie n t s h o u l d b e taught h o w t o p e r fo rm the exe rc ise wi l h resis ta nce .
M A N AG E M E N T A N D
S E L F- T R EATM E N T
C HAPTER N I N E
T h e p r e ie r red d ire ction o f en d - ra nge re d u c t i ve movements needed fo r red ucing p e ri p heral derangemen ts v a r i es at d i fferent j oi n t s
.
Generally, the mo re plan e s o f m o v e m en t that a re available at the
J Oi n t , for i n sta n ce at t he hip a nd s h o ul d er , then the g re a te r the v a r i a b i l i t y o f re d ucti ve d i re c ti o n s t h a t m a y need to b e t ried Symp t o m atic and mechan ical responses need to be eva l u a te d rather
than
re l y i n g on reci pe-book s o l u tions . Each cond i t i o n is d i fferent
a n d o ften the re d u ct ive movemen ts can on l y be fo und b y fu lly ev a l ua ti ng sym p t omatic and mechanica l res p onses to loading. Forces
may be req ui red i n an y plane of movemen t , weight-bea ring or non weight -bearing, wi t h o r wit h o u t the addi tion of tracti o n , loading into
the b l oc k a ge o r static resisted l oa d i ng , and m a y or may not need cl mician forc e s . At
the sho u l d e r res p o n se IS v ariable , a l t h o ugh l o adin g in m ed i a l or
latera l r ota t i on
,
with o r witho u t resistance , is o ften use fu l At the
e l b o w resp onse is c om mon to extension or flexi o n , wi th or withou t resistance , a l t h ough late ral m oveme n ts are a l s o sometimes needed . At the w r i s t response can be gamed fro m sag i ttal or frontal plane
movements, o ften with be tter resu l ts when traction is add ed The .
te m pero-mandi b u l a r j o in t fre q u e n tly needs o pe n i ng , ra re l y ever cl o si n g The h ip may res p on d to flexio n , e x t e n s i o n or r o ta t i o n .
m o v e me n t s . Alterna tive p ro c e d u re s a re weight-bearing rot a t i on pe rfo rmed by t w i sting on th e a ffected l e g , and a n o n -weight-bea ring move ment fro m flexion to extensi o n , performed by s tanding with t h e una ffected leg o n a step a n d qmckly stra ightening the leg. At the k n e e , fl e x i o n a nd e x te n s i o n a re t h e m o s t c o m m o n re d u c ti v e
m o v e m e n ts
.
1173
174 1 C H A PT E R
NINE
TH E H UMAN EXTREM I T I ES:
M EC H A N I C A L
D I AG N O S I S
& TH E RA l' Y
The foll owin g p h o tos re p resent s o m e exam p les o f e nd -ra nge l o a d ing t h a t may be required in the reduction of articu l a r d e range mems
I
Pbotos 28, 2'), 3 0 Eyternai rotation of fhe bip with a n d lUithout oue/jJressure t o be applied tell times different starting positions. -
28
29
Photo 3 i internal rotation of fhe hi!) 1I 'ftb and withou.t ol'erpressllre fo be applied tell Urnes.
30
31
Ci-I A rTE R
M A N A G E M E N T lI N n S E L F - T R E A T M E N T
Phutus 32, 33, 3 4 Different fIl ethods uf ClfJjJlying flexioJ1 a t tbe hip
witl) ul'erpressure
(ten times).
12
II 34
33
Phuto 35 Sustained k l lee extensiun, most useful in treating derangement o bstruct ing the la s t few degrees of extension. Huld for 20-3 0 seconds, relax. Repeat up len titnes.
� 35
to
NINE
1175
1 76 1 C H A PT E R N I N E
THE
H U MA N EXTRE M I T I ES: M EC H AN I C A L
D I AG N O S I S & TH E RA PY
Photo 3 6 Knee exte nsion
with
or without overp ressure. Pressure o n , prf'sstlre
oj! l e n
t i m es.
36
I
Photos 3 7,
38
Knee extensio n with ove,pressure wilh internal or exlernal pressure
37
off,
ten times.
38
mta tio n. Pressu re
0 11 ,
M A N AG E M E N T
AN D
S f:l F-T I( E AT M E N T
C H A PT E R
Photos 3 9, 4{), 4 1, 42 r:tIJOll' extensiot! with olleljJresslIl'l!. Starting witb tbe arm in full )lexiot!, tbe patient rapidly [mil abrupt/)! 'throlL's ' the ann into end-range extension. O l letjJressllre is achiel'ed }i'om the high velocity oj the procedure
39
40
41
42
NI N E
1 1 77
1 78 1 C H ! \PT E R N I N E
T H E H U ,vI A N E X T R E M I T I E S : M E C H A N I CA L D I A G N O S I S & T H E RJ\ PY
43, 44 Elbow jlexio n with overpressure wi th jorearm supine or prone. Pressure pressure off, t e n times. Photos
44
43
Photos 45, 46 Late ral overp ressure in extension at tbe elbow
extension
Oil,
by tbe o lher
band
and
The
affected a rm is
held in
cou n terpressure jrom the table, o n wbich the
patient is leaning. '[be jJatient liJen p ushes liJe elhow laterall), as jar CiS {hey can ten limes.
45
46
M A N A G E M E N T A N D S E L F-T R EA T M E N T
Photos 4 7. 48 li'action with dorsalll 'ell/ral gliding fnr derangement of the wrist. Fix the fO real1U against tbe bo dy Raise and lower tbe wrist while maintaining tractinn witb tbe other hand. Lateral gliding, or t r a nslation, CillI be ap/Jlied in the sCime mannel:
47
48
C H A PTE R N I N E
1179
I
1 80 C H A PT E R N I N E
&
T H E H Ui'vt A N E X T R E M I T I E S : M E C H A N I CA L D I A G N O S I S
T H E RAI' Y
Assessment s he e t - knee deran gement
Figure 9 . 1
TH E M c K E N Z I E I N STITUTE P E R I P H E R A L ASS E S S M E NT
Date
. .1
.
1
.
.
.
Name
...... .....@ F
A d d r ess
D a t e of b i rt h Work
. ........1
I L e i su re
P o s l u res
I
I
. .
. . .
. .
.?:£:>
Age
.
e\cC+C \ 6:<X:\ ." h�\� ·
. . .
S t res s es
.
. . . 59w:a.\h�
. . . .IJ..."Seci · :-\<.)· · p\a"'\ F u n ct i o n a l d i s a b i l ity f rom
fc£:)\Qa \\ . · ·�· · · 9 . . Q
present
e p i so d e
�c \<..i �
.
.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
.... . c;,:torred �l:-b:a.\\ /��I�
SYMPTOMS
H I STORY Present
since
.
h�
-R.\�t
P r esent symptoms
.!.
.
. .
C o m m e n c e d a s a r e s u l t of
c;;o. 'tes:.\oc
. . .
..
\\ p:;> :::i'l: �\aC
�uS\. .i3I� �c,.xafu""9.CD ·2\ (fb at\ .
J '"t---.
(""0CQ �
.
..<::, l m prov i n g l(u nC h a n g i ng"\ Worse n i n g
q'c:E:fu::c
.
c::'i:3'1
. . . .
or n o a p p a re n t reason
�::��i�"'���9C:���;�?��" �:'�� ;� C o n t i n u e d u s e makes t h e pain
Pain
Yes
at rest
Disturbed night
I
No
Yes
O t h e r q u es t i o n s
. . . . . . .
�... . . �::=:. .
. . . . -h..� ::::, h=-9 . · .
.
.. . ...
. .
.
. ;S�\\.e.D . · · · U-D\=c.K:::, ·...x · · i � · �....\: ... ·
k� .
..
.
No EHect
§Q
Better S=�--h,�
. . Bl. . . .b. I'"
.
. . . . . .
i . :5==e.*, r0e:::::, b.crs J � . 5b"acp ps.:IC).S . . . . .
.
.
:c:. c:.b
• �.
2> :> episode . . . -:-Sat:::�
Trea t m e n t t h i s
. . . . . . . . . . .Q� .
P r e v i o u s episodes P re v i o u s treatment
. � p<3UC\ � �CO\ ep\�::::' 7 ,-\e:.aC �D
S p i n al h i story
.
. .
Medicat i o n s : t ried
.
. . . . . (\512\ \. D
Effect
. . .
health
I maging . S u m mary.
C\<.:;:;:><:;:;rl .
. . .� . Acute
?
I
SUb.acut�
S i te s t o r p h y s i c a l e x a m i n a t i o n
8
1 nsidiouS onset
.
.
. . c::x-:e
Paraesthesia
.�I;: be:\�
P re s e n t medication
General
�e;\
. .
15l . . Yes
�
MANAG EM E N T
S E L F-T REATM E N T
AN D
. k('("'�
PERIPH ERAL ObservatiOn
O-I MTE R N I N E
f"'f:\\D\ �\
Active m o ve m e n t
6u.:::e.\lI
nq
.,
Loss .
.
. . . . . . . . E)< . n;:--,(""f",,�
ERP
�0 .... ..... . .. � ....
r-\'I'�' K'I�\ .
· · · · · · · · · ·
. . . . C'C)\.""<'r�).\ . .
.
PDM
Passive mov e m e n t Loss . ( +I-ove r-p ressu re)
. l=k.",,\ <:::s2)
.� . . �X \ .E:::C\;:::;� .
Resisted tests R e s p o n s e .
\'C:>
r.e,C',
prod uces , radiates ,
. . . . . . . . . ... . f\e�\CJC:'I
. . . . . . . .E..)(_h=c"'>� \.c:C'I . . .
EHect o f repeated tests o n move m e n t :
. . . ... . . . f\e� c.C'l
i ncreases,
better,
�u(gcL .
c;j::X:::'\ \ :::::t- ed
decreases,
worse,
.
. .. . . � ..
n o beNer,
n o wors e ,
n o effect
. . u..:� :::cx . . . . . . . . . 1:=:e-\\e'S . . . . No Effect
Worse
Better
.
E-rl:G E:D��
. �. .
�\:.e.). . .
abolishes, localises,
·
ERP .
rG\ D\� \Q:::':::'
. C'\C'f't C\,,--�:::...
E ffect o f repeated tests o n pa i n :
Loaded
<;:V,,,,\ U cl0 <..':::l'cK:;h9 .
PDM
£\e)(\£::[,\ .
Static P o s i t i o n i n g
..
. .....� . . .
EHects
I U n loaded
SPI N E Move m e n t �oss .
EHect
of repeated move m e n l s :
EHect
o f s t a t i c posi l l o n i n g :
Spine lesting:
g
o N
;;; § ;;;
�
E
(N
ot rel
e?l
R eleva n t I Secondary pro b l e m
CONCLUSION
Spine . .
D y s f u n c t i o n : Art i c u l a r
(6€
rangeme
.1i)
C o n t ract i l e
_ E::X:l: .En 5\ .:::::,e-..,
Postu ra l
Other .
U nc e rt a i n
PLAN E x e rc i s e
Frequency
. ..
E.><.X.EC\0\C:C::\ . . . I,.),J\-t':':\. � .: ��C::G.-\.Ce. .
. c\' .
. P-�, �c...e. . . . .
. . . �u��
·
I
·
. . e-,_�� . . d . .�
. . . x, . . . . \0 . . . . .
bC'tee." �
. .
s
1 181
1 82 1 O -[ A I'T E R
NINE
T H E H U M A N E X T R E M I T I E S : M E C H A N I C A L D I A G N O S I S & TH mA I'Y
Ch ronic pain sta tes As is clear from th e e p i demi olo g i c a l s t u d ies rev i ewed in C h a p t e r O n e , pe rsi stent musculos k e l e t a l sy m p to m s are c o m m o n ly I'mm cl througho u t the popu l a tion and a re frequ e n t l y e n c ou n te re d in hea l t h servic e s . The evi dence also s u ggests t h a t commo n l y u s e d t re a tme n t s o ft e n fa i l to provide these p a tients wi t h l as ti n g re lie f. Ch ro n i c p a i n b y i ts ve ry n a tu re i s resis tant to t re a tme n t , b u t t hese p a tie n ts d eserve the o p timum manageme n t strategi e s , even if c o m p l e te re h e f fro m s y m p toms is not possi ble . D u r a t i o n o f sy m p to m s s h o uld ne v e r be seen as a re ason to deny patients a tho rou gh mechanica l examination Many p a t ie n ts with persistent p roblems w i ll be c l assifi a b le i n o ne o f the m e c ha n i C<:t i s y n d ro m e s , a n d m a n y c a n a c h i e ve re s o l u t i o n , i mprove ment o r b e t ter se l f-manage m e n t o f t he i r p rob l e rn re l a t i vely easi Iy. However, in some patien ts s y mp tom re sponses ma)' be cont radic to ry, con fUSing or non-specific , a n d no clear-c u t mechanical d i a gnosis can be m ad e . In s u c h instances a test p e r i o d of repeated m o vemenls ove r a few days may h e l p to cl ari fy the re s p o nse C h ro n ic p a i n responses and behavi o u r c a n s o me t imes mask a n d c o n fuse an u n d e r l y i ng mechanical disord e r. O n ce the abnormal s e n S i tivity has s e t t l e d , a mechanical re sponse may be fou n d I f this fails to u n e a r t h a s p e c i fi c exercise a p p roach , the p a ti e nt s h o u l d b e c lass i fied as c h ronic a n d a gene ral g ra d e d exercise progra m me be imp lemenLe d . Va r i o u s n o n mechanical [a c t o rs m a y be m o d u l a t ing chro n i c p a i n - fo r insta n c e , neuro p hysio l o gical changes in the peri p h e ra l and cen t ra l n e r v o u s sys t e m , o r b e l i e fs a b o u t pain . The complexity of chronic pain has been most wi dely exp lo red re l a t i ve to spinal pro b l e m s ; less work has been done which pert a i ns d i re c t l y to extremity J o in ts
N o nethe less , i t is pro b ably fai r to e x t ra p o l a te
ce rtain compone nts of this c o m plex picture to a l l musc uloske le tal pains . The e vi dence s u ggests that peripheral j oint and m u s c l e lesions th a t have a n in fl a mmatory e lement a re qu i te cap a b le o f i n d u c ll1g both peripheral and centra l sensi tisa tio n . This involves the re d u ction o f pai n thresholds , an a m pli fica tion o f resp o nses , p ro longed p o s t stimulus sensations , pain response to nom1ally i n nocuous mecha n ica l s tim u l i , spread o f h e ighte n e d sensi tivi t y t o u n i nj u re d tissue a n d spon taneous pain ( Cohen 1 9 9 6 ; M e nse 1 9 9 7 ; Levine 1 9 96) I n o t ner word s , neurophysiological mechan i s ms m e a n tha t the link between the i n tensi ty of the noxious s t i m u l i to t he tiss ue and the p a in experi e n c e d by the patient n e e d not be c o rrela t e d at a l l . Pain may be
C H APT E R
M A N A G E M E N T A N D S E L F - T R E ATM E N T
the p ro d u c t o f p l a s t i c c h a n ges i n the central ne rvous system and not re l a l e d to local tissue d a ma ge . A m a l fu n c tioning nerv o u s system can e x agge rate pain res p o nses. Psych o lo gi c a l fa c t o rs have a ls o been associated w ith c h ron i c p a in S p e c i fi c p e rso n a l i ty t r a i t s w h i c h m a y p re d i sp o s e t o p e rsi s t e n t s y m p t o m s re l a te t o fe a r-a v o i d a n c e beha vi our, heightened an x i e ty and s o m a t i c c o nce r n , l ow self-dfi cacy, b e l i d in an external hea lth l o c u s o f c o n t ro l , and p a s s i v e c o p i n g stra t e g i e s ( P h i l i p s 1 9 8 7 ; A c k e rm a n a n d Stevens 1 9 8 9 ; J e nsen e t al. 1 9 9 1 ) Thus , aspects o f t h e p a t i e n t'S pe rso n ali ty can c a u se e xagge rated a n d dispro p o rti o n a te pain b e h a v i ou rs . The fa c t o rs that would appear to be most Sign i fi c an t a re fe a r-a v o i dance behav i o u r and se lf- e fficacy S o c i a l a n d e c o n o m i c fac t o rs a l s o a p p e a r t o have a r o l e in the d e v e l o p m e n t of pain a n d d isability M u sculoskeletal sym p t o ms and co nsequ e n t d isa b i li ty have been ass o c i a ted with l o wer e d u c a t i onal ach i e vement and fa m i l y i n c o me ( C u n ningham a n d Kelsey 1 9 84) , a n d s y m p t o m s o f s t re s s h a ve p re d i c t e d t h e o c c u rre n c e o f m u s c u l os k e l e t a l d isord e rs (Le i n o 1 989) . lVlost health p rob lems mflict d i s p ro p o rt i o n a te ly o n those who e nj oy the leas t prosperous l i festyle - gen e ra l l y l h e re is a l i near c o rrela tion b e t ween lower social c l asses and i n c re a s i n g
m o r ta l i ty
and morbi d i ty (Ra d i c a l Statis t ics 1 9 8 7)
M u s c u l o s k e l e t a l p ro b l e m s a r e n o e x c e p t i o n t o t h i s r e a l i t y (C u nn i n gh a m and Ke lsey 1 9 84) . I t i s s u gges ted that c hro n i c pain be seen as a biopsychoso cial phenomenon , with i n te rdependent soma tic, cognitive a n d e n v i ro n m en t a l d i mensions ( C o hen 1 9 96)
A clin i c i a n 's
inte ra c t i o n "vi t h p a t i e n ts t h u s n e e d s to e m b race this com plexlty I n s u m mary, v8rious n o n - mechan i c8! [actors can a ffec t the modulauon o f pa i n . The pain science p e rs p e c tive stresses the n e u rop hysiologica l c h a nges t h a t c a n h a p p e n in t h e c e n t r a l n e r v o u s s y s te m . T h e psychology p e rs p e c t i v e stresses t h e fea r o f pain , t h e l a c k o f s e lf effi cacy, and the passive c o p i ng s tr8 tegies . The soci etal perspe c t i v e s t resses the e nv i ro n m e n t8l c o n t e x t such as w o r k a n d family which i n fl u e nces t h a t indivi d u a l . It is l i k e l y tha t d i ffe re n t fa c to rs , o r a c o m b i n a t i o n o f fa c t o rs , m a y b e m o re i m p o n a n t in d i ffe re n t i n d iv i d u a l s . I t i s l i k e l y tha t i n some these factors a re rev e rsible while i n o t h e rs they a re n o t . Presu mab l y in indivi d u a l p a t i e n ts t h ese d i ffe re n t fa c t ors can be mo re o r less relevan t - as in s o many c l inical p he no m e n a a c o n t i nuum is l i k e l y t o e x is t , with severe irreversible cha n ges at o ne encl , and m i l d reversible changes a t the other. The
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preva lence o f the m o re e x t reme cases as a p ro p O r L i o n o f a l l t h ose w i th persistent pain i s u n k n o wn but is l i kely to be s m a l l . The c h ron i c pain p o p u la t i o n i s a h e te roge n eo u s gro u p w i t h t h e m aj o rity a t t h e l ess severely disabled a n d not i rre vers i b l e e n d o f the con tinu u m . In t his cont e x t it is w o n h n o t i n g t ha t , in those w i th ch ronic spinal pai n a t leas t , 60% o f t h i s gro u p d e line t h e i r p a i n as mild and 3 0 % as modera t e CMagni et al.
1 990)
I n t h ose w i th se vere
and pers is ten t p a i n , n e a r l y h a l f have no activity l i m i t a t i o n as a resu l t (von Korff e t a l .
1 9 90)
Afte r two years , 1 3 - 3 6 % o f t h ose w h o h a d
h a d chronic pain n o longe r rep o rted p a i n a s a p ro b lem, wh i le fo r t h e re st pain h a d become less frequ e nt and caused less d is t ress ( Croo k e t
al.
1 989). 1 t i s c l e a r from this e p i d e m i o l o gical d a t a t h a t p a t i e n ts wi t h
c h ronic pain are a he terogeneous gro u p . I t i s l i ke l y t h a t t h e y w i l l p resent with a v a riety o f me c h amcal and n o n - mechan i c a l fa c t o rs affec ting thei r p a i n , and v a ry ing d e grees o f seve r ity a n d d isa b i l i t y I t is d e ar t h a t indi vid u a ls may leave the c hro nic pa i n p o o l as we l l as e n t e r i t . T h e c l i ni c a l i m p l i c a t i ons o f t h i s a re t h a t p a t i e n t s wi t h p e rsistent pain may respond e a s i l y t o mechan i c a l t h e ra p y, o r t h e y m a y respond o n l y pa rtially, or some m a y n o t respond a t all I m p roved self- management strategies fo r the i r p rob l e m may bendit a l l p a t i e n t s w i th chronic proble ms .
Management O ften pe rsis t e n t symptoms will resp o n d pOS i t i v e l y to a n e x e rc i se p rogra m m e . S o m e times the res p o nse w i l l be sl o w e r, wi t h an i n i t ia l aggra va tio n , and o ften the o u t come i s i m proved m a n a ge me n t ra t he r than reso lu t i on o f sym pt oms A t ri a l o f progressive , grad e d e x p os ur e t o a n e x e rcise a n d ac tivity progra mme sho u l d be e n c o u rage d . Man age ment o f c hro nic pain 1S a c o m plex fie l d b e y o n d t h e s c o p e o f t h i s text . Howeve r, as i t so c o m mo n l y encountered , s o me gu i cl e l i nes fo r a general appro a c h wil l b e g i ven . These w i l l b e a d a p ted fro m e x p e rience gai n e d in ma nagi n g those w i t h c h ro n i c s p i n a l pai n . For chro n i c m u sc u l o s k e l e ta l p ro b l e ms i t i s re c o m m e n d e d t h a t
a
cognitive-behavi oural frame w o r k is used [o r i n t e ra c t i on w i th t he p a t i e n t (Tu rner
1 9 96)
Th is re qu i res
awareness o f and enquiries i n to psychologica l ' ye l l ow Gags' t h a t sugge s t ina p p ropria te pain behaviou rs and b e l i e fs a b o u t pa i n , and t h a t can b e ris k fac to rs for t he d e ve l o pme nt o f pe rsisten t pai n
M A N A G E M E N T A N D S EL F - T R. E A T M E N T
a p p ro p r i a te i n formation p rovision - the impo rtance o f the sel f m a n a geme n t principle for o ngoing health prob l ems , a c t i vity for m u s c u l o s k e l e t a l c o n d i t i o n s , a n d r e a s s u rance tha t p a i n o n m o v e me n t does n o t mean a n exacerba tion o f t h e p ro b l e m e n c o u ra g e m e n t o f a g ra d u a te d , s y s t e m a t i c resu m p t i o n o f a c t i v i ties C o m m o n fea t ures of s u ccessfu l p rogrammes for b a c k p roblems have been i d e n t i ri e d ( L i n t o n 1 9 98) . These might easily be a p p l i e d t o all m u scu l o s k el e ta l cond i t i o n s : mu l t i d i mensi o n a l v i e w of t he prob l e m , including psychosocial aspe c t s
a t h o ro u gh ' l o w t e c h ' exa m in a t i o n com m u n i ca tion o f t he findi ngs to the p a t ien t , a n d a n explanation
o l w h y it h u r ts and how t o bes t m a n age it e m p hasis o n self- c a re and e x p l a n a t ion that the way the p a t i e n t be haves I S integral t o the recovery process red u c e any u n fo u n d e d fe ars o r a n xie ty a b o u t the pain C h u rt
d oes not mean h a r m ' ) c l e a r rec o mme n d a tio ns ab ou t s t a r t i n g normal a c ti v i ties and a graded a p p roach to exe rc ises do not medica lise the p robl e m ; avoid ' h i gh tech' inve s t i ga t i ons , l o ng-term s i c k leave , a n d ad viSing the p a t i ent to ' t a k e i t easy'
T h erapi st tech niques and passive m oda l ities This te x t i s p ri rn a ri l y conce rned wi th e n d o rsing a sel f-manageme n t a p p ro a c h L o p e r i p he r a l m uscu loske l e ta l p roble m s . Th i s i s logica l in
the l i g h t o [ t he e p i d e m i o l o gy, t h e poor e fficacy o f commonly used t re a t m e n t , and the impo rtance , phYSiologica lly and psycho logically, o f t h e p a t ie n t ta k i ng co mro l o f their trea tme n t . T his b o o k d oes n o t p rescri b e a l i s t o f clinician tech niques ; many such bo oks a l re a dy exist . M o s t t e c h rll q u e s d escribed and p i c tured w i l l be ones that the patient the msel ves ca n use ; few books have p re v i o u s l y concentrated on this as pect or manage m e n t
C 1-1 A rH R
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Clin i c ian proced u res I f no i m p rovement follows fro m the a p p l ication o f the p roced ures reco mmen ded for the patient , it may be t ha t techni ques of fric t i o n a l massage , m o bilisat i o n or m ani p u l a ti o n a p p lied to the a lle cted structures could assist recovery Howe ver, in line w i t h the ph iloso phy beh ind this text , it is a lways recommended t hat hands-on techn iques shou l d n o t be employed as a firs t o p t i o n , a lways as a last o p t i o n -r he use of c linician tech niques before the patient has been a b l e to expl o re their own ability to p romote re covery only serves to u nd e r line t h e p o w e r o f t h e c l i n i c i a n a n d t h e d e p e n d e n c e o f t h e p Zl t i e n r Furt h e rmore , there i s no guarantee t h a t hands-on Lechniques w i l l necessarily result i n a better ou tcome . 1 f tha t o p tion i s chose n , the procedu res described by those w i th l ong expe rie n ce in the di agnosis and treatment of mechan ical m usculoske l e t a l d i sord e rs s h o u l d be considere d . It is not the purpose o f this book to prov ide a description o f those ma n u a l techniques as they are a l ready well d o c umented See , fo r examp l e , Cy riax and Cyriax ( 1 9 9 7) ; M a i t land ( 1 9 9 1 ) ; Lasl e L L ( 1 9 96) ; a n d Kesson and Atkins ( 1 998)
Passive moda l ities PhYSi o t herapy students spend many h o u rs learning a b o u t the t heory and practice o f various electrotherapy mod a l i ties Al though their value is negligible , some electro t he rapy interventions are still widely used U ltrasou n d , fo r instance , is said t o be used in about 1 0 % of an kle and knee d i sorders (van Baar
et
a L 1 9 98a ; Dekker
and Delitto 1 9 9 7 ; Roeb roeck
et
a l . 1 9 98a) However, these studies
et
a L 1 9 9 3 ; Je tte
may seriously under- report daily phys iot herapy practi c e Surveys fro m the U K , Austra l ia and Canada show that u lt raso u n d is avai lable to virtu ally all res p onding depa rtments and p rac tic es and is used on a d a i ly basis
in
over 90% of them (Pope
et aL
Spurr i t t 1 9 9 8 ; lindsay et aL 1 9 9 0 , 1 9 9 5 )
1 9 9 5 ; Ro bertson and It wou l d appear tha t
ultrasou nd is the most widely availa b l e and most commonly used elec trop hysical age n t inte rnationally (Robertson and S p urri tt 1 9 98) Because it appears to be the most w idely used electrOLherapy modal i ty a mong p hYSio the rapis ts ,
it
is usefu l to exam i ne u l traso u n d as an
examp le o f passive the rapies . The p ropo nen ts of u ltrasound advoca te its use to relieve innammatio n , reduce oedema , relieve pai n , acce lerate tissue repair, increase circulation and modify sca r fo rmation (Maxwell 1 9 9 2) I t is used in a wide range of musculoskeletal conditions (ler
C HA PT E R
M A N A G E M E N T A N D S E L F - T R E AT M E N T
H a a r 1 9 8 8 ) Lo g i c a l l y, s u c h a tool should b e used p rimarily d u ring the acute p hase of any m u sculoskeletal d i s o rder. whereas in fac t many
c l i n i c ia ns c a r ry on u s i ng
it b e y o n d the fi rst
few weeks (van Baar et
a t . 1 9 9 8 ; J e t t e and D e l i L t o 1 9 9 7 ; R o e b roec k et a l . 1 9 9 8 a , 1 9 9 8 b ) Whde iL i s t hought t ha t u l traso u n d h a s a n anti- i n fl a m m a t o ry e ffect
and e n h a nces tissue re pai r fol l o w i ng s o ft tissu e damage . i t s aCLUal e ffec t is l a rgely unknown ( M a xwe ll 1 9 9 2 ) Those inves tigations that
have bee n d o n e a re m ostly e xperimen tal . f re q u en tly using an imal models ra t h e r tha n c l i nica l stud ies . Clinical s t u d i e s th a t have been
d on e so fa r a re gene ra l l y of very p o o r q u ality ( K i tchen and Partridge J 9 9 0 ; Gam a n d Johan nse n 1 9 9 5 ; van der Wi n d t el a l . 1 9 99 ; H olmes and Rud land 1 9 9 1 ) The experimental work is gene r a l ly contradictory ( K i tche n and P a rtridge 1 9 9 0 ; Max well 1 9 9 2 ) , and the evi d ence t h a t
ul traso u nd has some a n t i - i n fl a mma tory e ffe c t is lacking. In an animal e x p e riment u l t raso u n d has been sho\v n to have no a n t i i n fl a mm a t o ry -
efTecl ( G o d dard et a1 1 983) . I n pa ti ents the an t i - i n fl amma tory activity has been a ttr ib u t e d to the p l ac e b o e ffec t a s the results were simi lar in the re a l a n d s h a m u l trasound gro u p s (Nya n z i et a l . 1 9 99 ; Hashish e t a l . 1 9 8 6 ) a n d fou n d t o be s o sma l l as t o lack c l i n i cal re lev a nce (Snow a n d Johnson 1 9 88)
In th e tre a t m e nt of s p e c i fic cond i t i ons the re su l ts of u l t r a s o u n d t h e r a p y have b e e n e q u a lly d i sa p p o i n t i n g . A very p o o r success rate has been fo u nd when U S i n g the moda l i ty for late ral e pi c o n d ylit i s (Stra t ford et a l . 1 9 89) , and i n t he tre a tm e n t o f acu te l a tera l l i ga men t s p ra ins ul t rasou n d w a s no b e tte r than p l a c eb o (Nyanzi et a l . 1 9 9 9 ) I n a re v i e w o f t re a t men ts
fo r l a teral e p i condylitis . i t w a s concluded
that a l t ho u gh u l traso u n d may have a therapeu tic e ffect i t was unclear
if this was a n y be t t e r th a n placebo (Labelle e t al. 1992) In a sys te ma t i c rev i e w o f trea t m e n ts fo r s h o u l d e r dis o rd e rs i t was concl u d e d th a t t h e re i s e v i d e n ce L h a t l,ltraso und i s i n effe c t i v e for these c o n di ti ons (van der H e iJ d e n e t a l . 1 9 9 7) A me ta-analysis p e r fo rm e d to eva l u a te the p a i n - re l i e v i n g v a lu e o f u l t ras o u n d conc l u d e d tha t i t h a d a n u nim p o rt a n t ana lge s i c e ffe c t a c ross a variety o f d i s o rders ( G a m and
J ohan nse n 1 9 9 5 ) Ano t h e r meta-analysis c o nc lu d e d " t h e re s e e ms to ,
be l i t t l e e v i de n c e to s u pport the use oj u l t ras ound t h e ra py in the
t rea tm ent oj m u s e u / o s h e letal d i s o rders . The l a rge m aj o ri ty oj 1 3 ra ndo m i s ed placebo - c o n t rol led t r i a l s w i th adequate meth ods did not suppo rt the ex istence oj c l i n i c a l ly i mpo rta n t or s ta t i s t ica l ly s i g n iJi c an t d iJJe ren c es i n Ja vo u r oj ul tras o u n d t h e rapy " (van d e r Windt e t al.
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EXTRE M I T I ES:
M EC H A N I CA L
D I AG N O S I S & T H E RA I 'Y
The fa ct that u l trasound is w i d e l y ava i la b le and re gu larly used
d e spi t e an a b sence o f s u p p o rting cl i n ica l research is test i mony to t h e opti mistic c l a ims o f t h e manu fa c t u rers , w h o obv i o u sly bene ri t fro m i t s a v a i l a b i l i ty. T h e n a i v e a c c e p l a n c e o f l h e s e c l a i m s b y t h e physiothera p y pro fess i o n is augmen t e d b y t he p lacebo e ffec t ( N ya n z i et a l .
1999;
Hashish e t a l . 1 9 8 6 ) , w h i c h g i v e s t h e c o m fo r t i ng
appearance o f e ffi cacy ; this expla ins c l i n i c ians' e m p ir i c a l ' fe e l ing' that i t works
Th e e vi d ence tha t is available not on l y s e riou s l y q u e st i o n s the worth of this i merve n t i on , b u t also raises the poss i bil i ty t ha t i t may be doing more harm tha n good ( M a xwe l l
1 990)
1992 ;
K i tc h e n a n d P a r t r i d ge
Certain s t u d i e s , fo r ins tance , suggest that u l t rasou n d may
cause vasoconstric t i on ra t h er than i n c re ase blood s u p p l y ; i n c re a se h i stam i n e release and cons e q u e ntly p ro d u c e m o re i n fl a m m a t o ry e x u d a te ; lovver the effe c t iveness o f mac rop hages i n figh t i n g i n fectio n ; a n d a lso p ro d u c e e x cessive a m o u n t s o f c o l l a gen a n el scar t i s s u e (Maxwell
1 99 2 ) .
" The dosage shou ld be c o n s i d e red cClrefu l ly i n t h e
l i g h t of ex i s t i ng e v i de n c e ; u l t ra s o Lwd c a n be d a m a g i n g a t h i gh
i nt e n s i t i e s within the 'therap eutic ' ra nge " ( K i t c he n a n d P a r t r i d ge
1 990)
The empirical p ro p osa l that u l traso u nd h a s a n an t i - i n lhmma t o ry and p a i n -relie v i n g e ffe c t is cle a rl y n o t su pported by t h e ava i lab le e v i d e n c e . F u r th e rm o re , i n Lhe a c u t e phase i nc o r re c t usage m a y a c tually be making the p a t i e n t worse Relian ce u p on s u c h pass i ve m o d a l i ties ignores the phYS i o l ogical i m po rta nce o f m o ve m e n t i n muscu loskeletal d isord e rs . Whe n used a s pa rt o f a 'shotgu n ' a p p roach to these p roblems it i m p l i c itly do'Vvnp lays the imp orta nce of p a t i e n t involvemen t i n trea tmem and i s s t i ll of l i t tle val u e . The re seems Lo b e e v i d e nce t hat u l t rasound is not e ffective as a n ad j u nc t to e x e rcise (van cler Wi ndt e t al .
1999;
Holmes anel R u d l and
1 99 1 )
T h e re is no
reason to be lieve tha t t h e comb ined e ffects o f ( w O o r mo re t re a tments
\>vi I I p ro d u ce a summation of the incl i v i d u a l t h e ra p i es ( Ho l mes and Ru dland
1 9 9 1)
The more thera py that is gi ven the gre a t e r t h e p l a c e b o
e ffe ct , b u t there is n o e v i d e n c e tha t u ltrasound produ ces a n y c hange that o u t lasts the gi v i n g o f' th e ra py ( F e i ne and Lund
1997)
M A N AG E M E N T A N D S E L F- T R EATM E N T
The psychol ogical rami fications o f such a n approach may b e t o p ro m o te i a t ro ge n i c disab i l i ty As w i t h a l l e l e c tri cal m o d al i ties , the treatment i s p red ica t e d on the ro le o f t h e p assive p a t i e n t re ceiving thera py fro m
the d ispensi n g clinician . S u ch a passive , uninvolved role for the patient con t radicts the actively i nvo lved role of the p a tient that is the o p timum c o u rse o f managem e n t fo r m u scu l oskeletal condi tions . I t has been s uggesled that in t h e fie l d o f b a c k pain such p assive managemen t stra tegies have hel ped p romote i a t ro ge n i c d isabi l i ty (Wa d d ell 1 998) .
C H A PT E R.
NINE
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T H E H U MAN EXTRE M I T I E S : M E C HAN I CAL D I AG N O S I S
& T H E RA PY
CHAPTER
10: Common Disorders
Introduction As has been discussed earlier in the book, the issue o f dia gnOSiS presents p ro bl e ms about reliability and validity. It is o ften less relevant to m a n ageme n L Lhan the stage of the d i sorde r and the p atient's
response to their painful condition. However, some specific musculoskeletal conditions are rela t ively simple to identify and a re commonly seen. The a ppl i ca t ion of mechanical di agnos is and therapy
can be mos t simply exemplified by discuss i on of som e re cog nis ed disorders. Other patients present with non-specifi c disorders to whi ch it is difricult to apply a clear-cut d i agnost ic label Lack of a dia gnosis
,
however, does not mean an inability to treat. Cat ego ris ing patients' conditions by the mechanical syndromes outlined earlier and with k n o w l edge o f connective tissue responses to injury and stress d ep r i vat ion
,
the appropriate man agement strategies s h ou ld be
appa re nt from t he history-taking, phys ical examination and symptom responses Generally in the first week following injury relative rest is briefly
needed to prevent disruption of the heal ing tissue, but from that time on most non-inflammatory musculoskeletal conditions need progreSSive movement and loading The quality o f co nnective tissues
decline \v"ith lack of use and reach optimum fu nction with incremental usage. Painful tissues become sensitised and deconditioned when not used so that normal movement becomes more painful and the area around the injury becomes tender to the touch. The individual is d iscou r age d from using the limb normally, and develops avoidance
behaviour. By introdu cin g pa tien ts to g r adua l p rog ressive load ing str ategies and an a ctive, patie nt ce n t re d management approach -
,
clinicians offer patients a way to improve tissue health and function, and allow them some understanding a nd control of their p roblem so that It is no l on ger of such concern. With some conditions the load ing needed is very specific to stress the tissues in a spec ifi c way, but w ith other conditions the important thing is simply to get the patients movin g and using the limb. Cl in i cians may find that patients often do not present with an easily recognisable s peci fic condition. Signs and symptoms may be vague
and non-speci fic, and a diagnosis cannot be rea ched. This does not
TEN
1191
192 1 CHAPTER TEN
THE HUMAN EXTREMITIES:
MECHANICAL
DIAGNOSIS
& THERAPY
mean that the clinician is unable to institute treatment. As long as attention is paid to the stage of the disorder and the symptomatic response to repeated movements, it should be perfectly feasible to commence an exercise programme This will be based upon the patient's responses to repeated active, active assisted, active plus overpressure or resisted exercises. Frequently the patient's response to repeated movements will in fact provide more useful information than a diagnosis A diagnosis does not, for instance, distinguish between the inflammatory and dysfunctional stage of soft tissue conditions. This chapter contains descriptions of some speciCic musculoskeletal conditions that are commonly seen in phYSiotherapy departments The natural history and appropriate patient management strategies are also described. The amount of detail relating to each condition is in part a reflection of literature that is available, which is frequently
limited in its scope These conditions are intended to exemplify how mechanical diagnosis and therapy can be applied to problems in peripheral joints Mechanical diagnosis and therapy have a role in all musculoskeletal conditions. This chapter is not a complete
account of all instances when this approach may be used. It seeks to give concrete examples of how to apply the mechanical evaluation and treatment strategies outlined earlier in the book to certain speci fie conditions. It is hoped that interested cliniClans, applying sound clinical reasoning skills, will then be able to apply the same approach to other peripheral musculoskeletal problems.
The spine and periphera l joint p roblems It is very common for lumbar or cervical spine problems to refer pain into the limbs. This may occur with or without nerve root involvement, as somaric spinal structures are implicated in diffuse radiating pain, sometimes as far as the foot or hand Such symptoms can occur with very little local spinal pain. Usually such problems are clearly related to the spine and there is no cause of confusion between spinal and non-spinal disorders. In extremity joint problems the pain is usually localised around the involved structure, sometimes with distal referral as well. For instance, shoulder problems can refer as far as the hand, lateral epicondylitis can refer down the forearm, and osteoarthritis of the hip can be felt in the groin, anterior thigh and even medial shin. Hip osteoarthritis can also present as localised knee pain with no groin or bUllock pain. Agam, m these instances
COMMON DISORDERS
CHAPTER
the dilTerential diagnosis between spinal and extremity joints is rel a tive l y straightforward.
Any peripheral Joint pain that is associated with proximal pain, es pe ci al ly in the scapular, top of the shoulder or buttock areas, strongly suggests that there is a spinal component to the p roblem The presence of nu mbn ess or paraesthesia is a further clue to the p r oble m originating in the spine When symptoms are felt in the
extremity but are not affected by mechanical te st ing of the local joints and muscles, again it is important to test the s p in e
.
Given the
propensity of s pin al structures to cause referral of symptoms
into the limbs, it is paramount always to discount this as a source of pain before focusing on the e x tremi ty Relative to the lower .
limb, a
M c K enzi e
lumbar examination procedure should be carried
out (McKenzie 1981) With all shoulder problems it is wise to first exclude involvement of the cervical spine before commencing treatment at the shoulder.
Cervic a l problems can mimic shoulder lesions to the extent of painful anel even restricted shoulder movements (Wells 1 982 ; Schneider
1989) Involvement of the spine should always first be disco unted
with the use of a McKenzie cervical examination procedure (McKenzie 1990) Sometimes it may be helpful to test range of movement, or pain eluring movement at the shoulder both befo re and after re peate d cervical movements; if the shoulder movements improve, treatment should start at the spi n e . If neck movements have no effect and the primary moveme nt dysfunction is at the shoulder, assessment and
treatment should concentrate there Concomitant neck pain is also very common in th ose with separate shoulder p roble m s and is a ,
high ris k factor for persistent or rec urren t shoulder p robl ems (van der Windt et al. 1996) In such cases it is generally better to start treatment at the neck, although both problems should be addressed. It is important to start with the pro bl em that is of prime concern to the patient
Rotator
cuff
tendonitis
Pathology of rotator c u ff muscles would appear to be the most co mm on cause of shoulder problems - different studies cite this as the cause of s y mp t o m s in 30 - 75% of their sample CChakravarty and Webley 1990; Chard and Hazleman 1987; Chard et al. 1991;
van der Windt et al. 199 5 ; Vecchio et al. 1995) The supraspinatus tendon is most frequently affected (Cofield 1985; Fukuda et al. 1994;
TEN
1193
1 94 / CHAPTER TEN
THE HUMAN EXTREMITIES: MECHANICAL DIAGNOSIS & THERAr'Y
Chard et al. 1988; Herberts et al. 1981) The p at h ology may involve micro-failure, acute or chronic inflammation, fibrosis, degenerative
changes, partial or comple te rupture of the tendon, and impingement of the tendon underthe acromion (Cofield 1985; B lev in s et al. 1997; Herberts et al. 1981) Because of the last factor pain may be produced
during abduction of the am1 in a specific arc of the movement. Because of the varie ty of pathological ch anges that may be found, the condition is best viewed as a continuum in which the slate of the tissues differs in individual patients. The condition has several synonyms rotator
cuff disease, supraspinatus tendo nitis, painful arc or impingement syndrome, etc . Patients may present with a c onstant or intermittent ache depending on the stage of the condition. G enerally range of movement at the sh oulder is preserved and there is frequently a painful arc on
abduction. In cases of complete rupture active movement is lost, but passive movement testing reveals a full ra n ge of movement. Resisted movements are the key tests. With supraspinatus tendonitis, resisted abduction will be weak and will reproduce the patient's pain; there may also be some pain on resiste d lateral ro tation. Resisted lateral
or
medial rotation is painful if in fraspinatus or subscapularis are involved The average age of patients is over 50, they come from manual and non-manual occupations, and they may be retired or classified as housewives. Onset is rarely due to trauma, but related to overuse at work or domestically, and is frequently of unknown cause (Chard et al. 1988) Four elements are commonly said to be involved in the pathogenesis of rotator cuff tendonitis; these are either intrinsic to the tissues or extrinsic (Cofield 1985; Blevins et al. 1997; Neviaser and Neviaser 1990; Herberts et al. 1984; Neer 1 98 3 ; Uhthoff and Sarkar 1990; Fu et
al. 1991; Bjelle 1981; Fukuda 1994; Chard
et
al. 1994; Uhth off
and Sano 1997; Soslowsky et aL 1997). The consensus seems to be emerging th at the pathogenesis is multifactorial, and thus that the relative contributions of each wlll vary between indivi d ua ls These causes are:
vascular de ge n era tive mechanical stress anatomy
COMMON DISORDER5
CHArTER TEN
The area of the tendon that is frequently affected is a site of reduced v
ascu la rity. This appears to accelerate degenerative changes and leaves
the tissue vulnerable to further pathology. The relative avascularity also means that healing and repair processes are impeded The tendons degenerate with a ge, with the inciden ce of cuff tears increasing markedly
in
those over 40. The changes seen include
cellular distortion and necrosis, micro-failure and tears of the tendons, calcium deposition, fibrinoid thickening and disruption of the site of insertion into the bone. The anatomical factor that is of most significance is the impingement of the rotator cuff caused by certain structures. 'Hooked' acromions are associated strongly with rotator cuff tears. Spurs and osteophytes from the acromion or the acromioclavicular jo int can exaggerate impingement of the tendon. The circulation to the tendon may be im p ai re d by compression between the hume r al head and the
coracoac romial arch. Due to the close juxtapOSition of all the tendons of the rotator cuff, the capsule, the sub-acromial bursa, and the coracohumeral and gleno humeral li gaments les i o ns of the supraspinatus tendon may e asily involve and be complic ated by one of these other structures (Clark and Harryman
1992; Fukuda
et
al.
1994) Mechanical factors generally relate to overuse and static arm positions, WIth the compressive effect of the humeral head aggravated by raised arm working conditions, espec ially overhead. Rotator cuff tendonitis in
occu pational groups who work with their arms at shoulder level
showed an odds ratio of 11 (Hagberg and Wegman 1 9 8 7 ). The prevalence
in
welders has been found to be 18 % compared to 2% in
clerical worke rs (He rbe r ts
et
a1. 1 9 81) . Repetitive micro-trauma is
thought LO be a pr ime cause of degeneration
in
the tendons, with
localised failures leading to reparative, inOammatory or degenerative changes Although fibroblastic activity and vascular granulation-like tissue have been observed, this reparative process has never been seen to be successful in actually restoring the normal structure of tendon tears
(Chard 1994).
It is likely that a combination of factors
trigger symptoms in different patients, but a common denominator would appear to be the role played by degeneration, leaving the tendons susceptible to pathology. The condition can pass through various stages, starting with an inflammatory reaction to overuse-induced tissue trauma. Fibrosis and
1195
1 961 CHAPTER TEN
THE HUMAN EXTREMITIES: MECI-IANICAL DIAGNOSIS & THERAPY
thickening of the tendon and adjacent bursa may follow. At later stages innammatory cells are rarely seen, and the normal healing process appears to be aborted. Chronic tendonitis is thoughL to result from a failure to complete the reparative process so the tissue is never remodelled for normal use . Histological changes re lated to hypoxia are characteristic of chronic degenerative tendonopaLhy ( Lead bet t er 1 9 92) . Further degeneration, impinge men t wear and cumula tive ischaemic trauma can finally produce complete tears of the rotator cuff (Neer 1983; Blevins et al. 19 9 7; Fu et a!. 19 9 1 ; Gross 1992). At
different stages of the continuum of rotator cuff p athology the Lissues may be infl a m e d, he aling, a bnormall y fibrotic, chronically degenerated or ruptured . The pain-generat ing mechanism may be chemical or mechanic al, or both, due to abnormal tissue
-
the
impingement effect may also add an ischaemic element. Natural history and clinical course of rotator cuff tendonitis
Various studies have identified patients with rotator cuff tendonitis and then monitored their symptoms over the subsequent year or over seve ral yea rs. These patients have often received standard treatments such as steroid injections, physiotherapy or NSAlDs. The long-term ou tcome of many of these patients is not good . At one year about 5 0% of such patients a re still reporting p rob le m s (van der Windt et al. 1 9 96; Chard et al. 1 988); in a population of over 7 0s some 70% were s till symptomatic at three years (Vecchio
et
al.
1 9 9 5 ) . Having trea tment seems to confer no long-term advantage. Frequently individuals will have such problems but not seek help, accepting their symptoms and disability as a p a rt 0 f the ageing process (Chakravarty 1 9 9 0; Chard and Hazleman 1 9 8 7; Chard eL al. 1991) One systematic review of interventions for rotator cuff disease found that there is no clear advantage for corticosteroid injections over
placebos (van der He ij d en
et
al. 1996), while in another the o n l y
pOSitive finding was that a subacromial steroid inJecLion was better than placebo in improving the range of abdu ction (Green 1998) Steroid injections have been found to be better (Adebajo et a!. 1990) and no better than NSAIDs (White et a1. 1986). It is not clearly proven that steroid injections aid recovery. It would a ppear from these studies that the natural history of rotator cuff tendonitis is frequently one of persistent and lasting symptoms, and that standard treatments frequently do not make the outlook much better. This rather pessimistic pictu re accords with the role that degeneration has in producing and maintaining the condi tion.
COMMON DISORDERS
CHArTER
Manage ment and self-treatment exercises
H seen during the inflammatory pe r i od the patient is encouraged to ,
re st ri c t usage 01 the arm, especially any overhead or aggravating
activities Elevation by flexion is less likely t o cause im p i n gem ent than abduction, which i s best avoided. Then from ear ly on progressive
loa d in g of the involved tissues is needed t o promote a st rong tendon
that can \vi t h s t and the stresses of daily work, recreational and spor t ing
act ivities (Gross 1992)
Active movements through part of the abd uc ti on range, in the case
or a supraspinatus p ro bl em can be used to load the tend on i ni ti al ly. ,
As improvement occurs the range can be increased. Is omet n c resisted
abdu ction ex e rcise s can also be used early. These should re p roduce the patient's symptoms, whi ch fade within a few min u t es of stopping Exercises s ho u ld be re pe a t ed about ten times three or four ti mes d u ring the day, in creas ed to every two hours if th e res ponse is all right. These can be done pushing against a wall. To progress the
exercises re s i st an ce can be offe red at different p oints in th e range,
moving to w a rd s the t arget zone. As long as these are not aggravating
the sy mp toms , movement rema ins ful l and the painful arc becomes
easier, these can be pro g ressed onto co n ce n tri c and ecc e ntric
e xerci s e s D y n amic exercises can be done in the target zone, where .
one is found, o r t h roug hout the range of m ovemen t when no target
zone is foun d [f the p a ti e n t is seen with ch ro n ic symptoms, progreSSive exercises
are again very imp o rt a nt to prOvid e the stimulus for c oll age n fibril realignment and maturation, and reconditioning of s ensitised tissue. Dynamic and s t a tic abduction exercises could be used. An ad e quate range of late ral rotation is also important to reduce imp inge m en t ; if this is limi t e d the humerus im p in ge s much ea rlie r upon t he coraco ,
acro mial li gamen t (Caillet 1981b) The role o f the rota tor cuff as a
hu mer al head stabiliser should be remembered, as well as postural compo nent s s u c h a s thora ci c and shoulder g i rd l e mobility
(Dalton 1994) The value of eccentric exercises for chromc te nd on problems is their ab ilit y to facilitate maturation of a strong ten d on and reduce the risk
of injury re currence (Gross 1992; Fyfe and Stanish 1992) Given the greaLer loading that these e x e rc i ses generate, they should only be
considered d u ri ng the terminal stages of rehabilitation. Again, these
TeN
1197
1981 C H APTER TEN
THE HUMAN EXTREMITIES: MECHANICAL DIAGNOSIS
& THERAPY
may be temporarily painful, but this should quickly abate on stopping the exercises.
If needed, dynamic or static exercises can be used to stimulate tissue in which the healing process is suspended. The p a ti e nt will have had the problem some time, re maining relatively stab l e Once the exercises .
achieve a temporary aggravation of symptoms, a less vigorous loading
stra t egy is ad opted
.
CHAPTER
COMMON DISORDERS
TEN
P!Jotos 49
(some/ric abductioll oj the shouldet: The patient stands wilh lhe painful side near {f wall, with feet apart and {be affected {frill relaxed by their side.
Photos 50 Isometric abduction oj the shouldel: Stabilising their body so
/bey do
not lean into the wall, tbe patie n l
the wall, generating tension, bul tbe supraspinatus tendon. This position Is iJetd b"iejly and tben relaxed. The isometric exercise is repeated up to ten times. abducts the ann into no
movement,
in
1 199
200
I C H ArTEI, TEN
TH E HUMAN EXTREMITIES:
MECHANICAL
DIAGNOSIS & TJ-IERAI'Y
Photos 5J, 52, 53, 54 Finding the 'tmget zon e ' in a mtator cuffproblem. The patient exen:ises in mid-range through the arc "Jgrea/est pain up to ten times. If the pain is too severe, exercise short oj the target zrme.A similar planJor aI/ 1rIol'emenlS at other joints should be used.
52
5J
53
54
COMMON
DISOP,DERS
CHAI'TER TEN
Photos 55, 56, 57, 58 'target zone' -/)aill on abduction is similar CIt all /Joints, Exercise tbrougb jull rang!.' u/J to tell times and /lse a similarjilanjor ail mOlleinent" lit otberjoints.
No
55
56
57
58
1 201
202
1 CHAPTER TEN Figure 10.1
THE
HU,I;IAN EXTREMITIES:
MECHANICAL DIAGNOSIS
& THERAPY
Assessment sheet - rotator cuff suprinatus dysfuncti.on
THE McKENZIE INSTITUTE PERIPHERAL ASSESSMENT
.1 .
.
Date
.
Name
.. .
Address
I.
Date of birth .. L'-..
Work 1 Leisure
Age
:)\:: ' ..
. e\C\cr.
.
.
. .
t\S\('C'\
rOI:::ed.
le (W":-':>
Postures 1 Stresses
®F
Functional disabilily from present episode
Q, \,
....
. :3) L..\..uacc.
Present symptoms
c
Present since
. .1
Commenced as a result of Symptoms at onset
HISTORY
\<�:�","i
$:"ou\de,
.
. . .
. .. .
SYMPTOMS
C£'e...
,-\e.ac.
\'e.I\ . �j"c.: . ..
.. ..
.....�\-:-:c.L\\dec.
What pro du ces or worsens
\'-
�
Intermittent symptoms
:-C:\ . C D " )'\ f" .
.. x::ye).�d.
.. a:b d�c.+I=.0 , . \ .. . .. e\C�--nc� What stops or reduces
... C\e0.l:\e.
\.. .J
g
Disturbed ni ht
� @
Yes
Other questions
.\.. \ ::�
W
.
...
.. . L\e;::-::>..
�\cd.. �_ ,
...... . .
Continued use ma k e s the pain Yes
Or no apparent reason
::rc., lld.e.C C\,C\"t.:::L-
.
Constant symptoms
Pain at rest
Im provin g (unChangi� Worsening
o rse
No
Effect
I ) ,tte.:c::l0D\d::;,\D�. . �.C�
�b��.
Treatment this episode
00;:·C .
Previous episodes Previous treatment Spinal history
.�...
Medications: tried
'' D D:::,''''\
Paraesthesia
Present medication
Effecl
C'\\.\.
.. �Cd. 'f-c CC"'-_\..... ..
C:C,
.
eW_c \
General health...
Imagmg
Summary:
Acute 1 Sub-acute
Sites for physical examination
��
8:'C>1.j'de.C-
ro
�
Insidious onset
_
-
..
Yes 1 No
CHAPTER
COMMON DISORDERS
TEN
R_,cp'l:. ::::�u\:::\ec..
PERIPHERAL
DM,D,
Observation
�,
Active movement Loss
t\el'-...ICO
. .... ... &"
El'c:Yd\...\.Ccnc:.(� . . , u.\\ �� t::le'0,r-.c\ �x -
Passive movement Loss ( +I-over-pressure)
ERP.
,900
W" , ,qOo
. '" \
...... .. , .. , ..
ER P
PDM.
\o\EC5\CC�<::;C', .c .. ,DI\ ... ..... q\.e:C'C),h... JroeC�\��.d\....\C:h� . . ...DI\ . PO,C'-. . �L\.c±lc:.c-:. Resisted tests Response . PGID \o.\c>_(D\(,Q�l)<;::::C') c
Effect
.. .
. . . .
..
.
01
���
.
radiates,
�I-:::J\ed
increases,
abolishes, localises,
better,
no better,
Worse
no effect
no worse,
rcLC.c":".:>e
p(t::x:iLl ce:" . . ...... r:"C Better
Effect of repeated tests on movement:
decreases,
worse,
�c-duCf''''''::'' ..
Qb d u.ch CC':\
F�oc,�
.
produces,
repeated lests on pain:
l(X:)
. , . ,
�
Static Positioning Effects
Loaded I Unloaded
SPINE Movement loss .
Effect of repeated movements: .
Effect of static positioning:
Spine testing o o o N
§ �
Q;
E
c§
CONCLUSION
(15Y n� sfu
: Articular.
�
Relevant
relev
Secondary problem
�,
Spine ...
� ... ",5<-.>pn:""�i��
Derangement
Postural
Other
Uncertain
PLAN Exercise
Frequency
\\e.)(ICC"
XI'C) x \O Ce:2>\�\C.c\,DW\...\C..hCD .
x
� /4:
c::iq,'.", ,
.�3/4�'\ �
C .�.::>";:.
1203
204 1 CHAr'TER TEN
THE HUMAN EXTREMITIES: MECHANICAL DIAGNOSIS & THERAI'Y
Capsulitis of the gleno-humeral jOint ('frozen shoulder') 'Frozen shoulder', adhesive capsulitis and periarthritis are some of the many synonyms used to describe a condition that is frequently seen by physiotherapists. It may account for about a fifth or patients with shoulder problems who visit doctors and physiotherapists (van der Windt et al. 19 9 5 ; Liesdek et al. 19 97; Chard and Hazleman
198 7; Chard
et
al. 1991; Chakravarty and Webley 1990; Herberts
et
al. 1981; Vecchio 1995) It has been the subject of several reviews CRizk and Pinals 19 82; Owens-Burkhan 1987; Wadsworth 19 86; Stam 19 94) Although there are certain aspects of the conditIon that still generate debate, clinical features make it relatively easy [0 recognise after a certain period of time. Involvement of the other shoulder is not at all unusual (Shaffer et al. 19 92; Rizk and Pinals
19 82) Generally it has a spontaneous onset affecting people over 40, sometimes following an injury such as a fall onto the shoulder - in these cases pain is felt immediately and the stiffening progresses rapidly It is said to go through three stages: painful / 'freezing', stiff / 'frozen', and recovery / 'thawing'; these stages often extend over several years (Reeves 19 7 5 ; Rizk and Pinals 19 82) The actual presentation and palhology will depend at which stage the patient is reviewed. At its most severe, the patient complains of continuous aching in the shoulder with radiating pain spreading down the arm as far as the wrist. The aching is felt even at rest, especially at night; patients are unable to lie on the painful side when it wakes them All movements cause a Significant increase in pain, and activities of daily living are seriously impaired. Patients frequently describe difficulties with dressing, doing their hair and reaching behind their back There is usually a gross loss of all movements with (lexion, abduction, internal and external rotation being the most noticed, but the exact pattern
of loss varies between indivlduals. The key pathognomonic finding in capsulitis is that the movement loss is both passive and active
(van der Windt et al. 19 95; Croft et al. 1996; Jacobs eL al. 19 91; Dacre eL al. 1989; Bulgen et al. 19 84; Rizk et al. 19 91; Ekelund and Rydell 19 92) .
COMMON
DISORDERS
CHAI'HR
Natural history
The first and most p ainful s tage may last from a co uple o f months to eight or nine months, at the e n d of which the shoul d e r will be maximally contracted (Re e ves 1975)
Ar throscopic and surgical
stu d ies sugge st that t h e r e is an e arly infla mmat o r y p ro c e s s commencing in the capsule o r rota tor cuff, which as It abates is replaced by adhesions a n d cont ractures (Neviaser and Neviaser 1987; Fareed and Gallivan 1989; Stam 19 94) This acc o u nts for the varied clinical present a tions and pathological findings. The condition should be viewed as a continuum in which initial chemical p ain is replaced by mechanical pain as the problem changes f rom intense pain to pain and stiffness . The sti ff period, with pai n now present when any movement is taken
to its rest ricted end-ra nge, can last f rom four m o n ths to a year; the recovery of mo vement (the 'thawing' stage) has lasted more than two years (Reeves 1975) The mean duration of symptoms from onset to recovery has been shown to be thirty m o n ths, considerably more than ,,, hal is often op timistically quo ted (Reeves 1 9 75)
However,
the total duration varied from one year to three and a half years, and even at this point over 50% of the s ample s till displayed persisting loss of some mo vements (Re eves 1975) The natural history is thus baSically self-limiting, but in s ome cases can run an ext remely protracted length of time. Nea rly 5 0% of pa tients who have been followed ove r many yea rs repo rt some symptoms and d emons trate residual res tricte d mobility, although few rate their problem as serious at t his stage (Shaffer et al. 19 92; Binder et aL 1 9 84; Reeves 1 9 7 5). Managem ent
Active t reatment of patients with frozen shoulder p rior to the cessation of aching at rest is unwise. The condition at this time is prima rily inflammatory and exercises or mobilisa tion of almost any type will aggravate symptoms and may delay r ecovery. A t t emp t ing acti.ve t he rapy too early ca n easily cause the patient unnecessary increased pain on movement and increased aching at rest which may last for hours or even d ays. More gentle mobil isations are equally futile and achieve nothing. All but pai n less movement of the shoulder should
be avoid e d; sometimes pendul u m exercises reduce the intensity o f the ache.
if the patient is seen during the inflammatory stage, appro pria te NSAlDs or injections are generally deemed to be t h e treatment of choice. However, although frequently recomme n d e d a necd otally and
TEN
1 205
206 1 C H A PTE R T E N
T H E H U M A N E X T R E M I T I E S : M E C H A N I C A L D I A G N O S I S & T H E R A rY
co mmon sense wou ld su ggest that tois is a p p ro p r i a te t re a t m e n t , t h e i r effec t s are less cl ea r in t oe li t e ratu re . Some s t u d ies 11ave f o u n d a u s e fu l rol e for in tra-artic u la r ste r o i d inj e c ti o ns in inc r e as i ng movement and red u cing pain
U acobs e t a l . 1 9 9 1 ) ,
whde o t h e r s have fo u n e! t h a t they
give be n e fi t in t o e early s tages 01 toe co nd i t i o n o n ly, wi t h n o l ong term a d v an tage o v e r no t re a t m en t at all CBu lgen et a l . 1 9 8 4 : B i n de r et a l . 1 9 84) . Syste m a t i c reviews have lo u n d t h e overall evidence across mu l t ip l e stu dies fo r i nj ec t io n s for c a psu l i L i s to b e u n c l e a r (G re e n e t
a l . 1 9 9 8 : van der H e ij d e n e t a l . 1 9 96) T h e s t u d i e s d o , h oweve r, h a v e v a r i o u s m e t h o do l o g ic a l p ro b l e m s i n t h e i r c o ns t r u c t i o n , i nc l u d i n g l a c k 0 1" uni formity i n d e Fi n i t i o n o f s h o u l de r d isord e rs , he te rog e ne i ty o f i n t e r v e nti o n s , and t i m e o f a p p l i ca t i on - a l l re l e va lll
i n order t o make a n i n fo rm e d j ud ge m e n t a b o u t the e ffic acy of
an
i n terv e n t i o n . T h e role of N S A lD s in the trea t m en t o f s h o u l d e r com p laints i n ge neral has been a dd r essed by one s y s t e ma tic review
( v a n der Windt
et al.
1 9 94) The three tlials "vi t h t h e b e s t me tho ds s c o re re p o n e d s u pe r i o r s h o r t- te rm e ff i c acy co m p a re d to p l ac e b o In t hose t ri a l s w h e re t he ind ic a ti o n for use was p e ri a r t h ri t is , N SA lDs w e re ge ne r a l l y fo u nd to be less effec tive than a re Fe rence t re a t ment or c o n fe rr e d no s igni fi c a nt bene fi t s . The a u t h o r s c o m ment t oat in v i e w o f t h e adverse re a c t i o ns to N SAl Os re p o rt e d by 8 - 7 6 % o f p a t ie n ts , I"u t u re s t u d ies s oo u l d i nves t iga te the benefi t-risk ratios o f N SAlDs and a n a l ge s i c s I n other wo r d s , as a n t i - in fl a m matories a p p e a r to c o n fe r , at b e s t , o nl y s h o rt te rm gai n , b u t c a r r y w i t h t h e m r i s k o f gas t ro i n t e s t i na l a d v e rse rea c tions , perhaps ordinary painki l l e rs s h o u l d be t he fi rs t t re a t m e n t o f c hoi c e . S e l f-treatment exerc ises
Well into the c o u rs e of the d i s o rd e r, a n el p ro v i d e d all a c o i ng at re s t has s u b s i de d ,
a
mec h a nica l assessment can be considere d . T h e pat i e n t
sh ou ld first re c e i ve a fu l l e x p l an a t i o n re g ardi ng t h e na ture o f t h e p ro b l e m , t he n a t u ral hi sto ry a n d reassu rance that t h e c o n d i t i o n w i l l imp ro ve even w i t h o u t t reat m e n t . T he c oo i c e s o pen t o t h e p a t i e n t shou l d b e de a rl y m a d e . T h e p a t ie n t m a y do n o t h i n g , i n w h i c h case they can e x p e c t the pai n and limited m o v e ment to e v e n t u a l l y b u t s l o 'vvly re c o ve r over time . Alte rna tively, h e o r she m a y c h oose t o take a m o re ac t ive a pproach and com m enc e e xercises , w h ic h a t this stage i s u s ua l ly possible w i t ho u t r i s ki ng aggrava t i o n T h i s o p t i o n is usu a l ly t a k e n i f res tricted a n d pain fu l m o ve m e n t is p e r s i s t i n g w i th l i l l i e i m p rove me n t . T h e p a t i e n t s ho u l d b e g i ve n a s t r u c t ur e d exerc ise programme t o fo llow
C O M M O N D I S O RD E RS
C f l A l ' H R TEN
I t is wo r t h n o t i ng t h a t t here i s no ad van tage
in p a ssive
11l 0 b i l i s a t i ons o v e r a n d above exerci s e s a l on e . S e v e ra l tri a ls
have l o o ke d at the e ffe c t o f passive m o b i lisations ap p l i e d t w o or th ree times wee k l y fo r fou r weeks or m o re c o mpared t o re g u l a r e x e rc i s e s a n d o t h e r i n t e r v e n t i o ns , and n o
Pbotos 59, 60, 61, 62, 63
Recovery of medial rotatioH
in frozen sboulder or dysfu n ction of sbo u ldcl: Pa tie nt ,nust prog"ess exercise over months frorn tbe resfricted position to full range, using assistance fro m tbe other band as necessmy
sign i fi c a n t d i ffe rences were fo u n d I n one trial the mobil ised gro u p a ct u a l ly h a d greater re stri c t i o n in range of move m e n t a t l o n g - te r m rev i ew (Bu l gen e t
Slmi l a riy, N i c h o lson
( 1 985)
al. 1 9 8 4 ; Bin d e r eL a l . 1 9 84)
found that whe the r the patients
exerc is e d o n l y or rece i v e d passive mo b i l i s a t i o n as wel l , the movem e n t i n c reased a n d t he pain d ecreased , but w i t h no c l i n ical l y i m po r t a n t d i ffe re nces b e tween the two tre a tm e n t gro u ps
The pain b e h a v i o ur, w h i c h i s c h a rac teris t i c 0 1 dysfunc t i o n , sh o u l d be c o n s i ste n t l y evo ked - p a i n is produced on each move me n t , but is n o t w o rs e a fte rward s a n d goes sh o r e l y
a ft e r t h e m o v e m e n l
i s s t o p p e d . A n i n c re a s e o f p a i n
fo l l owi n g t h e s t re tch ing s o me times l a s t s fo r u p t o h a l f a n h o u r, b u t i l i n c re a s e d p a i n l a s t s fo r m u c h lo nge r, [ h e fre q u e n c y o f t h e e x e rcise , t h e n u m b e r of movemen ts o r
59
t he degre e of s t re t c h i n g s ho u l d be re duce d . P a tien ts m u s t always be g i ve n a c l e a r e x p lanation o f t h e pain res p o nse e xp e c t e d a n d w a rn e d to await re-assessme n t if the re is a s e r i o u s aggra v a t i o n 0 I' t h e i r condi tion A II exe rc ises s h o u l d be re p e a l e d te n to t we l ve ti mes in th ree o r fo u r sessi o n s d3 i l y lo r a fe w d a ys
O n c e t h e re s p o nse is c le a r a n d
accept3 b l e , t he frequ e n c y c a n be increased so th a t t h e y a re d o ne e v e ry l W O h o u rs .
T h e exe rcises gi ve n to t h e p a t i e n t w i l l depe n d u p o n their p a rt i c u l a r m o veme nt luss. S e l f- a s s i s t e d flexion is usually the easiest move m e n t to start with 'vv hen the j oint is severely res t r i ctecl ; t h is can be augme nted b y s e l f-assisted exten sion. As m o ve m e n ts get e a s i er o r if t h e re striction is less severe
i n i t i a l l y t h e n lhe loss o f ro t a t i o n s h o u l d b e worked o n . ,
60
Movements b e h i n d t h e back and head , which involve media l a n d late ral ro tatio n , a re fre q u e n t l y t he most severely a ffe c t e d and the last moveme n ts to recove r. It is genera l ly b e tter t o try to recove r m e d i a l b e fo re l a te ra l ro t a t i o n . Atte m p ts to S i m u l t a ne o u sly re c o v e r b o th m o v e ments or pro g ress the e x e rcise p rogramme too q u i ckly may r es u l t i n aggrava t i on of the sym pto ms
1 207
208 1 C H A P TE R T E N
T H E H U MA N
E X T R E M I T I E S : M E C H A N I CA L D I A G N O S I S & T H E R A P Y
For assiste d - llexi on the p a ti e n t sho u l d be shown h ow to c l asp hands together a n d , kee p in g the e l b ow s s t ra igh t , l i ft the arms as hi gh as p o ssIb le over the heael . As
with a l l t h e exercise s ,
th e pati ent is encou raged t o t a k e t h e m o v e m e n t as fa r a s possible a n d t o try t o increase t he ran g e o v e r ti m e T h e l irnit o f m ovemen t w i ll b e due to a m ixture o f pain a n d sti Hn e ss Assisted-extension may n e e d w o rk p r i o r to m e d ia l ro ta l i o n .
F o r extens i o n , clasp hands t o g e t h e r be h i nd t h e bac k and l i ft b a c kward s ; c a u t i o n a gainst l e a n i n g f o rw a rd
I f t h e y a re
unable to l i n k hands be h i n d their b a c k t hey may use a s t i c k ,
t o d o so . For in te rn a l rota t i o n the patient s h o u l d be i n s L ru c L e d Lo p lace the han d of t he a ffe cte d a nn b e hind t h e b u t t o c k If t ile patient
61
can reach eve n fu rther, p erha p s across to the b u t t o c k on t h e
o theT s i d e they should be encou rage d to do so . Alter reac hing ,
as fa r as possible the hand should be a l lo wed to re t u r n to t h e side a n d re st bri e ll y. T h e movement s h o u l d b e re p e a t e d a n d with e ach ,
repe titi o n the hand should m o ve across b e h i n d the b u ttoc ks and a t te mp t to slide higher u p the back By using the he a l t h y l i mb to assist with the m o v e m e nt a be tter r a n ge o f m o v e m e n t can be obta i ned
If clasping hands t o ge t h e r is initially d i fficu lt , a l o w e l achieve this .
62
63
can be used
to
C O M M O N D I S O R D E RS
C H A I' T E R T E N
Prov i d e d t here is no lasting increase in aching following the exercises , t h e p a t i e nt s h o u ld be instructed progressive ly to i ncrease the ra nge o f i n te r n a l ro ta ti o n p e rfo r m e d by t h i s mea ns . Once the h a n d on the affected side c a n reach t he l e v e l of the waist , the rec o v e ry o f ex ternal rota t i o n and e l ev a t i o n can be c o m m e n c e d . A t te m p ts t o recover exte rnal ro t a t i o n a n d elevation of the should er be fore recov e r i ng a d egree o f i n t e r n a l ro ta t i on may c a u se a p a i n fu l rea c ti o n , w h i ch in some cases c a n be s e v e re . T h e recovery 0 1· exte rn a l ro t a t i o n i s m o s t sim pl y achieved b y having t he p a t i e n t stan el racing agai ns t a walJ By sliding the h a n d as fa r as
p o s s i b l e up t h e wa l l , e l e v a t io n and e x tern a l ro ta t i o n a re b o t h enco u rage d . T h e p a t i e nt l owers t h e a rm a fter having reached as far as poss i b l e o r as far as pain w i l l perm i t . So that t he patient may have a v i s ib l e i n di c a t i o n of their p rogress it is help fu l to mark the daily ac h i e v e m e n t s o n a stri p of paper pi nned t o the wal l . D ur i ng a n y p a rt o f t h e programme sho u l d t h e in tens i t y o f the patient's p a i n i n crease a n d remain t h ro u gh to the fo l l o wing day, a red u c t i o n o f the frequ ency and i n tensity o f t h e exercises i s ind i ca t e d
.
If the
re a c t i on persists o v e r a w e e k to ten d a ys despite re d u cing t h e a moun t o f e x e rc i s e , a tL e m p ts to re cover fu n c t i on should be de l aye d or even a b a n d o ne d . C l i n ic i a n m o bi l i sations
If patient -generated fo rces a l o n e a re fa i l i ng to b ring about a satis factory improveme nt in t h e symptom a t i c o r mecha n i ca l p resentations , the
clinici an m a y consider su pplementing the se l f- trea tment p ro gramme
with
a n i n c r e a s e in
fo r c e by a d d i n g in c l i n i C i a n - ge n e ra t e d
mo b i l isati ons . As n o t e d a b o v e , t hese a re ce rta inly n o t gua ran teed to be any m o re e fficacious t han exe rcise a l one (Bulgen e t al. 1 9 8 4 ; Binder et a l .
1 98 4 ; N i ch o ls o n 1 9 8 5 ) , b u t a few sessions w i ll show if t hey are
of va l u e in b rin ging a b o u t so me change s . H a fter a few sess i o n s l i ttle has c h a n ge d , the p a ti e n t s h o u l d be a d vised to c o n t i n u e their home e x e rcise p rogra mme , wI d about the final goo d p rognosi s , bu t warn e d a bo u t t h e p ro t racted n a tu re o f t h e c o n d iti o n . Cl i ni Ci an-gene ra ted mobil isa ti ons s h o u l d reproduce t h e patient's pain d ur ing the manoe u v re , w h i c h shou l d abate quickl y a fterward s . Any lo ng-las t i ng aggrava tion of s y m p toms means tha t this increase in fo rc e l e v e l is not a p p ro p r i a t e . The mobil isations can address di fferent a s p e c t s of t h e m o v e m e n t l o s s . P h Y S i o l o gi c a l s tre tch e s c a n b e
1 209
I
21 0 C H A P TE R T E N
T H E H U M A N E XT R E M I T I E S : M E e H A N I C A L D I A G N O S I S &
TH E Rtd' Y
perfo rmed into fle x i o n , e xtension a d d u ct ion , l a teral ro tati o n , e t c . ,
Accessory m ovemen ts c a n be p e r fo rmed at e n d - range p h y s i o l ogical
m o ve me n ts
.
I f t h e re is
no
ra p i d , c l e a r i m p ro v e m e n t in l h e
sym p to m a t i c o r m echan i ca l prese n tati ons , t h e se p ro ce d u re s s h o u l d b e a b andoned and o n l y the p atie n t s t rate g ies con ti n u e d .
Photos 64, 65, 66 Recouery of lateral mtatio n a n d elevation iJ/ frozen slJoulder or dysfllnclioll sholiider The patien l should strive FJr CI bigbe/" mark lip Ihe lI 'ClII Ol 'er lillie.
64
(,6
(,5
of 117"
C O M M O N D I S O R D E RS
C H A P TE R T E N
Assess men t sh ee t - capsulitis : early s tage
F i gu re 1 0 . 2
TH E M c K E N Z I E I N STITUTE P E R I P H ERAL ASSESS M E N T
Date
.t .
Name
Add ress .
D a t e of b i rt h
../ ...
1 ...
Work / L e i s u re
�c C . . .
c>
Pos t u res / St resses
.
..
Age . .
0.0
u.::C)( .'i:: e..C .
c-:oe.d e"-c"'\ a A �
. . . . �\..::;:\ � �C) . . F u n c t i o n a l d i s a b i l ity from p rese n t episode .
\ \� j . . . . bc...-nC;:'es . . . dc.-;,.\'-� . \..-':;Q ( C \\,-C\cc\ d�C:..u\\. . . . . . C'f:.,t. ;'"J \..u,r.G�� c-
SYMPTOMS
"I
H I STORY
. Ie\\ . 1:"lcr-C\ i.. \oce.nr. ""
Present sym ptoms
Present s i nce
. . . . .1 . . .
. . 1 . . . . . . C\'e . .
<'CC:.Q\b .
I m prov i n g / U n Ch a n g i n g
C o m m e n c e d as a r e s u l t of .
..
. �-:-£;. . .
Symptoms at onset .
C o n s t a n t symptoms . . . . 0C . . . . . .
W h a t prod uces o r worsens
.....
........
.
D i s t u rbed n i g h t
O t h e r q u es t i o n s
..
P revi o u s t re a t m e n t
.
M e d ications: tried
Present medica t i o n .
General health . . . .
S u m m a ry :
..
l
S p i n a l h i s tory .
� �
�
. . . . . . . . 3/q.. . X
No
episodes �lCf)\ . .
I m ag i n g
.
...
ece..c \...\ . .
No EHect
C':\I�� ....... .......... .
.
.
Tre a t m e n t t h i s episode . P re v i o u s
¥->cc:.-acr:'C"\ ............
..
... . . (::=x::rC'e::h�. Better
No
.
�
:c:£.C":C) . . .G "C�...S"\�� ,:::-:. ., . . . . .ece� . . .
C o n t i n ue d use makes the pai n
CiiiJ ®
�
p a re n t re a s o
� . . . rC\IDI .N:'\a\ . . . . . .d·S..-S c...'-.\..\. \�-\ L�.;,h d(e.s:::,\DC".\ . , . . . . \-:\0.,(" , . . . . re?\C..bi� . .
2C\'-.\ .
\...� ... \\� C.Cl ·'-\; , �0d 'c>eb\cxj. 'c5i'::-\cj: W h a t stops or r e d u c e s . " . ce:::A .
P a i n at rest
I n term i tt e n t symptoms
�
� t '::::'
�
.
.d::x::) u IOe.C
e.c ::\" �·�,
�
... .......
. D::'"J B\D,. .
. � .. .
.
..
. . . . . . . ,:';)I\'C)\ .l8.C
Acute
EHect . "
: oC",,:AC\e.::::>\ C':::'
(SU b·acute P C h ro n i c
c.\.. . .\\ c:\e:c . . .
..
3 y:e..\2'l.C ;::, . . BC.� '- )
.
.
. . . ,C'C ,0C.
S i t e s for phy s ic a l examination . . . . . , .
.p::CA:::>\er:-o
ph:'jS,O:\\:.f:e qJ,,... \
............ ,"
.
Trau m a .
Paraes t h e s i a
C'c)\ \-:-;f.c:lp9
(0S
ei"j
i d i OUS o n s
Yes
I
No
1 21 1
212
[ C H A rT E R T E N
T H E H U M A N E XT R E M I T I E S : M E C H A N I C A L D I A G N O S I S & T H E R A PY
Observation Active m ovem e n t
LOS�:;�� <::�CX)°5�oPDM
. . . . . .
..
. . .
. . . . . . . .. .
.
..
. . . . . . . .
. . . . . . . . . . ..
.
ou\e bulDc .L c@
� l.=blDo .��t.
.. ERP
. ....... . POM
P a s s i v e m o v e m e n t Loss . .
� •••••• . .
.
(+I-over-pressu re)
\\e..\L'C:C'\
sndL -Ic:n c::f':':) .
\ LO "
'ICl\e�:&\ \C �1\cD
q'eD<>'r.u.crecC';;\
.
qO O .. .
:abdu ChO,
�o
R e s i s ted tests R e s p o n s e
EHect
of repeated
tests on
produces ,
pain:
radiates ,
abo l i s hes, loca l i s e s ,
decrease s ,
increases, better,
wors e ,
. \r)cc� e
SZ\e. lL\ c:J.,� . .
.
no
.
. . . . \(,)U:: e�.e. .
. . .e >0:e.D :--::.\.C.C'\
.
,
no
w o rs e ,
no eHect
l.,\.:iD cs e .
\J.,.,,� � <::'., No EHect
B e tt e r
E H ec t of repeated t e s t s o n move m e n t :
be l t e r
S t a t i c P o s i t i o n i n g EHects
Loaded
�
. . . ,-� .se . . . .
.
SPINE Move m e n t Loss .
EHect of repeated mov e m e n t s :
E H e c t o f s t a t i c posi t i o n i n g :
S p i n e testi n g :
�
R e l e v a n t I Se co n d a ry problem
(p" h-:;b ..
CONCLUSION
Spine . .
eriP
D y s f u n c t i o n : Articu l a r .
C o n t ract i l e
D e ra n g e m e n t
Postural
Other .. C8p8-\\ , nS
U nc e rt a i n
PLAN E x e rc i s e
Frequ ency
C O M M O N D I SO R D E RS
C H A PT E R
Assessment sheet
F i gure 1 0 . 3
- frozen
s h o u l d e r : l a te s tage
TH E M c K E N Z I E I N STITUTE P E R I P H E R A L ASS E S S M E N T
Date
.
/
.. .
.1
.
�F
Name Address
... / .
D a t e o f b i rt h . . . . . . . . . 1 . . Work
/
Age
63
..
Le i s u re
Postu res
/
S t resses .
FunCIi�n�I' dis�bllitY
...
f�t::�
PiS��� '
,-¥
p,cx::::lIe..r0."2:> nct"..::,--'x tvro
....... . · d<:llb h0\�
SYMPTOMS
H I STORY Presenl symptoms Present since
.
.
R' ��\- 0bau\d.eS" .
.
..
/
.. ...
.
../ . . . . . . . � .-
.
..
. . . . .
�
.�
� e
chang
........................ 0
C o m m enced as a re s u l t of Symptoms at onset
I m p roVi n
.
I n t e r m i tt e n t symptoms
C o n s t a n t symptoms
. . . . . .
.
. . .
.
L\p l 0uJ . .
.
. . . .
J3l CCCC\
. .
.
. . . . DO . . LDoC". .se. . . .
What stops or reduces
r��
ll>..>""1 h . u:::;e.. .. .
�,,-,""'\ :;:,n 9 'CS:l c(,(,) , . &"Dc::r-,.\O� . . . . . . . . . . . . . . . . . . . . � 'oe.b'DO 'c.-J:&d:..
What prod uces or worsens
Wors e n i n g
parent
!Ch;:j ;:::\:' .c:\e. . . . .
Better
C o n t i n u e d use makes t h e p a i n
N o EHect
�
Yes � ,
P a i n at rest
0!iJ
D i s t u rb e d n i g h t
No
Other q u e s t i o n s
. . . . . . . .�Q'-'Z:::t ::::;,
Tre a t m e n t t h i s e p i s o d e . . P revious episodes
. . . . . . . .
P r e v i o u s treatmenl
rc£'e . .
. . . . . . . . . . r0'e . .
.
. . . . . . . . c-:c:::c-e . . '
Spinal history .
Paraesthesia EHect
Medicat i o n s : t ried . P resent medica t i o n General health I m ag i n g
..
S u m m a ry :
.
. . . .
. . . . . . .
�. .
.
.
a r.e\ p
c
. o.� .
. . . . . . .
I'd:":e . . Acute /
S u b-acute
S i tes for physical e x a m i n a t i o n .
�
. . . . :st'OU\Oec
Traum�i d i o uS � on
Yes / No
TEN
1 21 3
214 1 CH APT E R TEN .. ..
. . . . .Q . PI ,�. . . .
Active move m e n t
LOSS �\e. )(j, = . .
PDM
\ 1.,\,.0 °
. . . . . . . . . 2\c:clw.c.f\C:C\. . . . . \C5:::JD recc\ . \:JebrD .� .
.
D I A G N O S I S & T H E RA P Y
. �S�\\de.C
PERIPHERAL Observation
H U MA N E X T R E M I T I E S : M E C H AN I CA L
TH E
Passive m o v e m e n t Loss . ( +I- o v e r-pre s s u re)
. . . . . . . �\<;;:. xicc\
€::R. P
. . . 0':),0 . b'-.-I \\D c.X..
PDM..
\l.\-Oc
\o.\e.CC\l\ comnee)
� RP
. .....
-::::,00
, E-R, p
j
. .. E R P .
. . . . . AbduCh O� . \00
Resisted tests Response .
. . C\ .f\.u. . . E ffect o f repeated tests o n p a i n :
p rod uces ,
abolishes,
rad i a t e s ,
..... . .. � :&-.I�
loca l i s e s ,
i n creases, better,
. . . . . . . . . . . . . p(DOUCE . . . . bcDd . bebIC'\d . .�CL . . . . . . . . . p rQ(j.uce.
decreases ,
worse ,
n o be tt e r,
B e tt e r
Effect of repeated tests on m o v e m e n t :
Stalic P o s i t i o n i n g Effects
Loaded I U n l oaded
SPINE M o v e m e n t -Loss .
Effect of repeated m o v e m e n t s :
Effect of s t a t i c p o s i t i o n i n g :
S pi n e t e s t i n g :
.. ...
o
�
�
CONCLUSION
�
De ra n g e m e n t Other . . . . . . . . . . . . .
c
�
Vi oS .,
.� '" " ::; Q)
"' fQ)
@
�
v a nt
I
Secon d a ry p ro b l e m
P e r i p h e ra l .
.� (§Sfu n �9JcMic uiab , ��
�
R el
. C-rou\ o.e.C .
Spine . . . . C o n t ra c t i l e Postu ral .
.. ,
U n ce rt a i n
PLAN Exercise
F r e q u e ncy
�X--> � . . .>:< . . . . . . \0 . . . . . . . . . . . . . )( 3/4-- �,ty b:::cn 1.:::P --hI\\d �c'c. . . . . . . . . . .:><.. . \0 . . . . . . . . . . . . l'-. �l'-+-,
n o w o rs e ,
no
effect
C O M M O N D I S O R O F RS
C H A PT E R. T E N
Lateral epicondylitis (,tennis elbow') ' Te n n is e l b o w ' is a c o m m o n comp l a i n t w i t h a n i n c i d e n c e o f fou r t o s e v e n p e r 1 00 0 p a t i e n t s , w i t h a p e a k in th e 35 to 5 4 a g e grou p , a ffe c ting i n d ivi d u al s fro m a l l o c c u p a tional gro u p s ( H a m il ton 1 9 8 6 : Asse n de l ft e t a l . 1 9 96) I t res u l t s I-rom p a rtici p a tion i n many activities t ha t invo l ve the use o f the w ri s t and e l b o w, causing a s train a t the c o m m o n o r i g i n o f the e x tensors of the w r i s t . I t is only someti m e s caused b y tenn is , b u t ten n i s p l ayers themselves a re frequen tly a ffec ted lt is c o n s i de ra b l y more comm o n than medial epicond ylitis (or 'gol fers
el bow') , and i s t h e most common muscu l o s k el e tal c o mplamt of the e lb o w ( H a m i l t o n 1 9 8 6 ; Coonrad and H o oper 1 9 73)
P a i n i s fe l t
a t the
t i p o f t h e e x t e rna l epicondyle o f t h e h u m e r us , b u t
c a n rad i a te d o wn t he d o rsal aspect o f the fo rearm . De pending o n t h e severi ty of t h e cond itio n , pa tients c a n p r e s e n t with a constant ache
that is aggra v a t e d b y re l a ti vely t n v ial a c t i v i ties o r an i n te rm i ttent a c h e p ro d u c e d b y gri p p i n g o r c l e n c h i ng of the h a n d a n d wri s t . Recogn i t i o n o f a p u re lateral e p i c on d yl i tis is straigh tfo rward . Most act ive a nd pass ive m o ve m e n ts a t the w ri s t and elbow d o not cause a problem , e xce p t some times w ri s t flexion wi th e lbow extens i o n , which stre tches the contrac tile s t ru c t ur e . A l l re sist e d moveme n ts a re p a i n fre e exce p t l o a d e d o r re s i s t e d extens i o n o f t h e wri s t , worsened w h e n
the e lbow
i s e x te nd e d . The movement re p ro d u c e s the pa tien t 's
pain ,
sometimes to such a n ex tent that t hey are u nable to hold the posi t i on . Dege n e ra t i v e c h a n ges o f o v e ru s e or age i ng frequen t l y have le ft the fib res o f the extens o r o rigins in an asym p tomatic but weakened state .
1 f rest from the aggra v a ting activ i ty is permi t t e d the t i ssues m a y reco ver, b u t cont i n u ed a n d cumu lative a c t i v i t y produces pathological changes a n d a n i n sid ious onse t of sym ptoms . The pathology, obse rved at s u rge ry, i s macro s c o p i C and m i c ro s c o p i c t e a rs i n t h e ten d o n . Gra n u l a ti o n a n d S UH t i ssu e fo rm a tion i s an a t temp t a t re p a i r - this con ta i n s free - ne rve end ings and t h u s is very pain ful when s tressed . T h e re p a i r p ro ce s s i s fre q u e n t ly a b o rt e d o r i n c o m p l e te . Acu te i n flamma t o ry cells a re not fou n d when p a t i e n ts get t o su rge ry. T h e t i s s u e p ro c e e d s fro m t ra u m a t o re p a ra tive , i m m a t u re granulation tissue and a d hesions w h i c h remain sensitive to n o rmal use . At the c h ro n i c stage the tissues are dege n e ra t e d , d e c o n d i tioned fo r n ormal use , a n d not re m o d e l l e d [o r fu ll fun c ti o n (Boyd and M c l e o d 1 9 7 3 ; Coo n ra d and H o o p e r 1 9 7 3 ; Wa dsworth 1 9 8 7 ; N irschl a n d Pettrone
1 9 7 9 ; N i rsc h l 1 9 9 2 : Leach and M i l l e r 1 9 8 7 ; N o teboom
et
al. 1 994)
1 21 5
21 6 1 C H A rT E R T E N
T H E H U MAN
E X T RE M I T I E S :
M ECHAN ICAL
D I AG N O S I S
&
T H E RA I' Y
I nitiall y, then, tennis elbow a p p e a rs to b e a n infla mma l o ry p ro b le m , while l a ter i t beco mes a mechanical o n e w i t h a b n o r m a l t i ss u e o f
a
dys fu nction . This ne e d s re modell i ng fo r n ormal use , sla rting w i t h gentle loads an d then p rogressing. A l ter natively the hea l i ng process is su spen d e d , i n which case vigorous s t i mulatio n may be re q u i re d to encourage a resu m ption of the re pai r p rocess Aga i n , i t is i m p o rtant t o v i ew this condition as a c o n ti n u u m , with di ffe ren t mechan i ca l and non-mechanical fac t o rs present at d i ffe re n t stages and in dHfere n t indivi d u a ls . T h e natu ral h i story a n d c l i n i c a l cou rse o f l ateral epico n d y l itis
Common t reatmen ts for this cond ition d o not resu l t in au t o m a tic resol u ti o n of the p rob lem. A syste mat ic re v i e w of c o r t i costero i d inj ections fo r lateral epicond ylitis fo u nd a ge neral tre n d that lhey were effective i n the short term at b esto w i ng bene fi t , bur n O L if t h e re was lo ng- term fol l ow-up greate r than six weeks (Asse n d e lft et a l .
1 996) A n other re view o f t re atme nts was un a b l e t o fi n d a c l e a r thera p e u tiC value i n u l t rasound , N S A l D s or i n j ections (Labe l le e t a l .
1 9 92) The key issue
in the c l i n ical c o u rse o f lateral e pic o n d y l i t i s i s
t hat although u l t raso u nd or stero i d inj ec tions may confe r s h o r t - l e r m b ene fi t with t h e latter b eing m o re e ffe ctive b u t associated w i t h more recurrences, the relapse rate is consid e ra b l e (Binder and H a z leman
1 983 , 1 98 5 : Clarke and Wo o d l and 1 9 75) A t six m o n t hs to a y ear in over 50% o f pa tients t h e sym p t o ms have pe rsi sted o r rel a psed Few patients seek me d i cal h e l p again , but may to le rate seve re p a i n o n u s e a n d accep t disab ility ( Clarke a n d Woo d land 1 9 7 5 ; H a m i l t o n
1 986 ; Binder a n d Hazleman 1 983) I t is clear tha t pers isten t , recu r rent and chronic symptoms are extremely co mmon in late ral epic o n d y l i t i s , and the condition can fre q u e n tly de fy all manne r of t rea t men t s . T h e role o f th e rape utiC exercise t o manage the prob l e m has n o t been much exp lored . However, patients w i t h c hro nic lateral e p i c o n d y l i tis who had failed to resp ond to i nj ection , m ed ica t i on or p h ys i o the ra p y w e r e t r e a t e d w i t h a p r o g r e s s i v e s t r etc h i n g a n d c o n d i t i o n i n g p rogram me a n d co mpare d t o treat m e n t with ul t rasound ( P ienmak i et
al. 1 996) . The exercise gro u p h a d Sign i fi c a n t l y l ess pain a t rest
an d, under e ffort, was mo re able to wor k and f u n c t i o n m o re no rmal ly Se lf-treatment exerc i ses
Patie nts w i th constant sym ptoms of re ce n t o nse t t h a t are eas ily aggravated may no t t o l erate mechanical t h e rapy The c o n d i tion m a y still b e a t a chemical s tage a n d res t , relat ive r e s t o r avoidance o f aggrav a ti.ng fac tors may b e necessary.
C H A PT E R T E N
I f t h e pat I e n t p re s e n t s w i th m o re p e rs i s t e n t
Photos 6 7, 68 Local compression in lateral epicondylitis.
s y m p w m s , e v e n i f c ons t a n t , a programme o f e x e rc i s e s t o t ry t o r e g a i n n o r m a l fu n c t i o n
sh o u l d be t ried
with
the thumb, or
extends and
Ida_yes
,
re m o d e l ling p rog r a rnm e is o ften go od The re mo d e l l ing p rogra m m e needs to a dd re ss b o t h t h e Il cxi b i lity and contra c t i l e s t r e n gth o f S t re t c h i n g i n v o l v e s e l b o w
e x te n s i o n , w ri s t fl e x i o n a n d m e d i al ro t a t i o n o f t h e \vho l e a r m - usually t he o th e r hand will be
nee d e d t o g e n e r a t e e n o u g h t e n s i o n t o the tissues fo r it to b e fe l t . F o r s t re n g t h e n i ng exe rc ises the p a t i e n t n e e d s w start a t a l e v e l
that gen era tes e n o ugh c o n traction fo r i t to be
67
fe l t w i t h o u t a ggrav a t i n g the c on d i t i o n i n a l a s L i n g way T h u s i t is o fte n b e t t e r to s t a rt w ith s L ati c m u sc l e c o n t r a c L ions L O tesL t he res p o nse . T h e p a t i e n t m a k i ng a fi s t or o ffe r ing s e l f fl s i s ta nee LO w ri s t e x tens ion can do this . All '
exercises s h o u ld r e p ro d u c e the p a tien t s p a i n , '
b U L i L sho u ld n o t l a s L on ceas i n g t h e movemen t . Exercises s h ou l d b e repeated 1 0- 1 2 times three or [o u r times a day initial ly, p rogressing to every Lwo ho u rs i [ L h is is well t o l e r a t e d .
I f s t a t i c re s i s t e d e x e r c is e s a re b e i n g e a S ily
patien t
index finger reinforced with the maintained, tbe pafient tbe wI·isl ten filnes.
the
m iddle jinget: With compression
I f the p a t ien t presents with
i nt e r m i L t e n t s ym p t o ms t h e i r res p o ns e to a
L he tend o n .
tbe
jirmly applies pressure to the painful extensor orig in
68
t o le r a ted or are n o l on g er c a u s ing disc o m fo r t ,
L he p ro g ra mme sh o u l d p ro g r e ss onto co ncent ric and then eccent ric wor k . S u c h d yn am i c muscle w o rk i s b e t t er a t p ro d u ci ng a st r e n gt h tr a i n in g e ffect thro u gh o u t the ra nge o f m o v em en t E ccentric training .
d e ve l ops gre a t e r te nsi o n in the musc le than c o n c e n tric w o r k , which
may cause m o re de layed onset muscle so reness , but is t hought to have a s u p e r io r t ra i n ing e ffec t ( N o rris 1 9 93) Such dynam i C train i ng c a n be a c h ieved using se l f-res i s ta n ce thro ugh range , weigh ts , flexi band o r gym e q u ipment See Pie nmaki e t aL ( 1 9 9 6 ) [o r a progressio n
o f exercises . If i m p rovements cease to occur at a ny p o in t a pro gress i on
can be
ma d e i nvo l V i n g t he pa t i e n t p e r fo r min g w ris t e x tens i o n o r c lenchi n g his or h e r fi s t , b u t a t the same time applying static co mp ressi on a t
1 217
21 8 1 C H A I'T E I1. T E N
T H E H U M AN E X T R E M I T I E S : M E C H AN I CAL
D I A G N O S I S & T H E RA PY
the tender si t e with the fin gers o f the othe r ha n d . The m i d d l e fi nge r c a n b e u s e d to re i n force t h e seco nd fi n g er as it ap p l ies p ress u re to t h e e x tensor o ri g in whi le they re p e at e d l y e x te nd a n d re l a x t he w ri s t .
Resisted exercises o r a ctive movements w i t h c o m p re ssion c a n be used if the co n d ition is no t res po nd i n g to remo d e l l i ng and ne e d s to be s timu lated m o re vigorously This w o u l d be us e fu l fo r p a t i e n ts with s t a b l e symptoms of a p ersistent n a tu re i n whom the h e a l i n g p rocess has b e e n susp e n d e d . Once a te mp o ra ry aggravation 0 [' s y m p toms
has b e e n achieved the more vigoro u s pro c e d u res s h o u l d be s to p p e d Some patients also fin d a c o m p ress i o n c l a sp w o r n J u st b e l o w t h e e lb o w t o b e use ful in al lowin g them t o pe rfo r m o t he rwise p a i n fu l activ i t i e s This shou l d b e re c o m m e n d e d fr o m d a y one i n a l l cases . .
Relief fro m pain in these cases is i m m e d i a te b U l re t urns o n ce the s t ra p p ing is remo v e d . I t is difficu l t to i de m i fy a p l ausible e x p l a n a tion for such re l ief.
' Pseu d o ' ten n i s e l bow o r e l bow d e ra n gement Ma ny pa t i en ts w i th the ty pical s y mp to m o f ' t e n n i s elbow' , which I S p a i n o n re s i s t e d w r i s t e xt e n s i o n , a l s o d e m o n s tr a l e a p a i n fu l obs tru c ti o n t o full ex tens ion o f the e lb o w. I f t he p ro h lc m is one
a ffe c tin g t h e co m m on extenso r origin , w hy is fu ll e x te ns i o n , a c t i v e and pa s s i v e restric t e d and pain fu l i n a su b s t a n t i a l mi n o ri t y o f s u ch ,
Photo ('9
Grip lesl 10 differen tiate derangement from tennis
elbow. The patie n t attempts to 11ft aga inst the clinician 's resistan ce wiJile keeping their elbuw straight. If Ihe elbow giues way into flexion, suspect derangement and tesf PH loss oj extension, Obstruction to extension amjlrms derangemenl.
p ro b l e ms ) Why is wrist e x t ens i o n w i th Lhe
e l b o w fu lly e x te n de d more pain fu l t han w he n i t i s sli g h tly fle x e d ) W hy do the symptoms re s o l v e w i t h the recovery o f [u l l extens i o n ) Some as y e t unexp lained in ternal d e ran ge ment
mechanisnL must be the cause
in
a
signi ficant
n u m b e r of cases , A gri p tes t may help to diffe re n t i a t e b e t we e n ' tennis elbow' a r iS i n g from d er a n g e me n t and ' tennis elb o w ' a ris i n g fro m strain o f t h e o r igi n o f the wrist e x tenso rs . The p a tie n t s t ro n gl y grips the cl inicians fingers at arm's le ngth and , keep ing their elbow max i m a l ly e x t e nded , pu lls up as th e clinician resis ts . P a i n of te n ni s e l b o w
may c a u s e giv ing way a t the w r i s t , wh e re a s 69
in
d e range m e n t t h e elbow i tsel f b u c k l e s i n t o
C O M M O N D I S O R D E RS
C H A PT E R T E N
fl e x i o n . La c k o f full e x t e n s i o n s h o u l d c o n firm the d i ffe re n t i a l d i agnosis Self-m anagem ent exercises In such cases exe rcise must address the art icu lar d e range ment
ra ther
lhan t he a ppa re n t contractile p ro b l em . Th i s is presumably the reason fo r M u l l iga n 's ( 1992) p r o p ose d me thod o f trea ting this cond i t ion using m obilisation wit h m o v e m e n t which he c l aims can give d ramatic ,
i m prove me n t s . The red uctive fo rc e recommended here i s a c o m b i n a t i o n o f e xt ens i o n and sup inat i o n The patient m u s t be instruc ted from maximal fl e x i on
to stra ighten the elbow as fa r as p oss i bl e wi th t he fo rearm in a p o si t i o n o f max im u m s u p i n a t io n . \N hile maintain ing ma ximum supination
the p a t i en t m u s t extend t h e e l b o w rapidly and ab ru p tly, release the s t ra i n fo r a bri e f m o m e n t a nd t h e n repeat the process len to fi fteen t i me s a s o f t e n as the o p p o r t u n i t y p rese nts . The m o v e m e n t mu st be
!"orced ru nhe r w i t h each e x cur s i o n a n d w i l l
ca u s e some pai n at
the
m a x i m u m p o i n t o f e x t e nsion. T h i s w i l l i m m e d iate ly s u b s i d e with
each c y c l e Ot r e laxa t i on . Te n t o fifLeen m o v eme n ts i n to extension s h o u ld be comp leted
i n one
minu t e .
Photos 7(). 7 1 . 72, 73 f\NnsirJII sc/f 1 l J o b ilisa tion for exlensioll derangem e n t at the elbow. will> o bstruction of extension. CommenCing with the ann in fu l/ flexion. tbe patient rapidl)' and abrupt/v extends tbe arm to end-range. keeping the forearm in Slipillatioll. OI'(!ll)1'(!s.wre is obtainedfrom IIJe bigh I'e[oeily generated by tbe 1 I1 0 l 'e m e n t. Tbis is repeated lIjJ to ten times.
70
71
1 21 9
I
220 C H A I' T E R T E N
TH E H U M A N E X T R E M I T I E S : M E C H A N I C A L D I A G N O S I S & T H E ll.A I ' Y
72
73
In the event th a t rep e a t e d
e x tension o f the e l b o w fa ils t o red u c e t h e
obs t r u c ti o n , the p a t i e nt must b e s h o w n h o w to a p p l y o v e r p ressu re using the healthy han d , w i th the a r m stab i l ised by l e a n i n g o n t o a t a b l e I f no imp rovem e n t fo l l o w s , severa l options a re a v a i l a b l e I f i t
seems tha t fu rther fo rce progress ions a re necessa ry L o p ro d u c e l a s t i ng re d u c t i o n o f the derangement , the e x t e n s i o n m a n i p u l a ti o n devised by Cyriax may be used (see Kesson a nd At kins 1 9 9 8 or Cyriax and Cy riax 1 9 9 7)
A l terna t i v ely, if sy m p L o m s a re b e i n g w o rs e n e d b y
exte ns ion a n d the b l o ckage is not be i n g re d uc e d , o the r d i re c L i o n s sh ould be exp lored . O n e p oss i b ili t y i s t h e u s e o f fl e x i o n , w i th the
forearm s u pi n a t e d and then p ro n a ted , w i th o ve r p ressu re p ro v i d e d
by the o th e r a r m . A late ral fo rce ma y be u s e d . As in the extension overpressu re , the a rm should b e stabilised by l e a n ing onto a tab l e , the other hand kee ping t he a r m in e x tensi o n and p r o d u c in g t he latera l fo rce by p u shin g onto the lower part of the hu m e r u s . A ft e r a l l manoeu vres , their valu e in reducing L h e derange m e n t sh o u l d
be c h e ck e d by re - a ssessing t h e response t o e x tensi o n .
C O M M O N D I S O R D E RS
Ph()los
C H A PTE R T E N
74, 7 5
wil/1 ol'l!/jJressure jor extension derangem e n t a t tbe app lies ove/jJressure witb fbe other hand. '( be /J r(lcedure is do n e witb tbe jorearm supina ted, tben pronated. If s llmptoms a re being wo rsened bJ' extension and lbe blockage is 110t being reduced, tiJe jJrocedure is dOlle witb tbe jorearm sup ina ted, tben p ronate d. Flexi() 1 l selj'l Iwvilisti tio l l
elb o w , Il'il!J obstruction 10 extension. Tbe pa tient
74
Photos
75
76, 7 7
derangement Cit tbe elbow. Tbe ann i s beld in band and co u n te rp ressure applied bl' us i ng the lable. 'be maximall), exte n ded elbow laterall), liS jar as pOSSible,
A ddu clioll sel{m o/Jilisali(J I l jor e,,,lellsio l l ll 'ilb
The /wtie l l l
Ihe
olher
then /lushes
IC I l tiln es.
76
77
1 221
1
TEN
222 C t I Al' T E R
TH E
& T H E RAP Y
- t e n n i. s elbow
Assess m e n t s h e e t
F i g u re 1 0 . 4
M E C H A N I CA L D I AG N O S I S
H U MA N EXTREM I T I ES:
TH E M c K E N Z I E I N STITUTE P E R I P H E R A L ASS E S S M E N T
Date
.
. . . . .
...
/
Name
.
.
.
.
.
.I
.
. . . . .. .
Address . . . . Date of b i rt h
Age
. . . . . . . . .1 . . . . . . . J . . . . . . . . . . . . CC;(::3'<_ .
Work / L e i s u re
Postures / S t resses
.
. . . .
\�-n�
. .
.. 9*, �..:::x::o ( 'c . . ..
�1":q:::"'i C:C'\:\S Pres e n t
..
C o m m e nced Constant
\,
5
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.
.
..
,� e\\=),,0
I nt e r m i tt e n t symptoms
night
Disturbed
� ..
T r e a tm e n t t h is e P i sod e P revio u s episodes P re v i o u s treat m e n t S p i n a l h i s t o ry .
.
.
. . . .
P re s e n t m e d i c a t i o n General health I ma g i n g
.
. . .
S u m m a ry :
. . . . . .
,
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Med ications : t r i ed .
c.'�e.us
. . . . CC\..U. . CDt \.0C:)«"�d el.b o ,,:::.:o / v.::.,(': , ;S\ . . . fT'O � �. . . .
-
N o Effect
,
... . ..
C\C::JC;C\ Acute
'
/
S u b- a c u t e /
S ites f o r physical exam i n a t i o n
.... . .
,
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.D.::--:>. B .I . D. S . . . .
�e. acrc'\ ..
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o
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O t h e r ques tions
,
. . . .
Cf \ pp'DC.::" .
. . . .
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C o n t i n u e d u s e makes t h e p a i n Pa i n a t rest
a �(EiSlS:-CD
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Ce51: ). . . 9eD\\-e
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reduces
.
.
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W h a t p roduces o r worsens
or
SYM PTOMS
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\o�a.\ d'Co;i)
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symptoms .
Wh a t stops
.
bu.-\-
.
.
H I STORY
a result of .
as
; N:?� . ' "
.cE:±......l cre.d u2� � Oll-
J
Symptoms at o n s e t
. .
. . .
symptoms
Present s i n c e
�
.
. WC::C b 9 . .
F u n c t i o n a l disabi l i t y f rom p resent e p i s o d e
. Cn:::-c> Cleec).
. 40
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a.
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sidioUS
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D I S O R D E RS
. ..
P E R I P H E RAL
Observation
C H A P TE R T E N
E::\'c:c ,.0
. . . . . .D , . P\
Active move m e n t Loss
. . . . E. \,OO. ....,,:) . . . .� . . . . . . . . ,,�\'\ 0\ :,
Passive m o v e m e n l Loss ( +I-over-p ressu re)
, "I) ,
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.
E.\bO'->.2l �J!..\ C'C)
Re s isted lests Response
. .T
,
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\!,.....i� I ;::Jl- f\C...uCC\ lJ.,..j� \h () P. \nc(e.cy'Ld , DCU,.\_"C'c� .
...
e \'<X;:; �() : . .
Effecl of repeated tests on p a i n :
prod u c e s ,
el'c::c:, ,--0 e: x'le\\�\CC':\
.
�\ . . .u... -r-. .., \�:/t.
(E£D.o� -to\...UE. \) ..
Effect o f repeated tests o n movem e n t :
CeRP ) A\\ e\s e
. . . . D E. . . .
ex �J'=Ir;:\e.x.\. a:::-. / prr:::r:-.�cr:-,/C>'-)Pi��
radiates, . ..
"
rc:, \"c\ c� p'C'?>"---'
.. . POM.
R�tec\ �.:::>\
9(:'�'0 4
Ejl<€ . . . . pcccsahCD / . .0.'-.1 p\cx:-�hc:\\ . . . . :a\\ . . . c\" ,---,\\ � a ('(-:'I . . . . . . . ' . .
\'\f�' J!.. \ ca . lc:x'r€.'.rc·s,C$2).. ..... � K-\Co l e..';\ \:er,;::J,cS'. . .
abol i s h e s ,
l o ca l i s e s ,
i ncreases ,
better,
decrea s e s ,
worse,
n o better,
no w o r s e ,
,,-
(lE.
no eHect
e.x..'Ie£D P.'I . . �
Belter
Static Positi o n i n g Effects
Loaded I U n l oaded
SPINE
Movement Loss
Effect of repeated movements:
Effect of static position i n g :
S p i n e testing
CONCLUSION
Gt ;�te� ��I��� n t " l Secondary problem
Dysfunction : Articu l a r .
�, S8;'�C'\::-:>
P o s t u ra l
Dera n g e m e n t
Other .
P LAN
Exercise
E\bow
c::&in tra�t�
. .. .... ...
"
Spine . .
.
.
.
:I:e.� i hC£':'.ed
U n certain
Fre q u ency
" . (p'ecc � jD\J.---e i» )<, la
GC'I=0\� . b'C:CA_�. ex �OAd-:'l.
.
""
�'�T r\ex.,.\C:rI . lD-:1:Ib . Cl P_ . . .
.
'!, 3/4- dc:;\\\ "1 . J' 3./U. ctN'I� )(., . . .\ 0
1 223
1
224 C H A P T E R T E N
T H E H U M A I'i E X T R E M I T I E S : M E C H A N I CA L D I A G N O S I S & T H E R A I'Y
Carpal Tunnel Syndrome The carpal tunne l is a ligamentous -osse us foramen j u s t below the wrist comprising the transverse c a r pal l igament and the c a r p a l bones . T h rough i t pass the tendons of Oexo r dig i to rum supe r rici alis a n d
pro fu n d u s and p o ll i c is longus and t h e med i a n n e rve . Dec rease
in
the cross-sec tional area o f the tunnel o r e n l a rgement o[ t h e L u n n e l contents can cause compression o f the media n n e rv e ( B l eecker l. 9 8 7 )
Th i s causes numbness a n d t inglmg in the d i g i t s i n n e r v a t e d b y the medi a n nerve - u s u all y the m i d d le and i n d e x fi n gers , the medial
aspect o f the thumb and the lateral aspect of t h e ring fi n g e r ; the l i ttl e
fi n ge r is spared . However, a typica l innervatio n paLterns a re s a i d to be common, and thus the l ittle fin ge r and who le h a n d c a n be i n v o l ve d (Keenan 1 9 9 1 ) . Sensa tion m a y b e reduce d a n d the p a t i e n t m i ght
c o mplain o f d rop p i ng things . As the disease progresses motor fu nctio n
is a ls o a ffec ted , a n d in e x t reme cases there m a y b e t h e n a r a tro p h y Pain may b e local ised to the wris t , but may also s ho w re t rograde
sp read to the e l b o w or shoulder - one of the few instances in whi c h p a i n i s re ferre d from d iscal to pro x i mal . Ty pica ll y the p a t ient wa kes in t h e middle
of t he nigh t , d is turbed by the s ym p t o m s and shakes ,
their hand to g a in some re l i e f (Caillet 1 9 8 1 a ; Szabo and Madison 1 9 9 2 ; Sola 1 99 4 ; Yassi 1 99 7 ) .
In
the early stages s y m p t o ms a re
frequently only felt at nigh t and no sy m ptoms fel t d u ring the d a y As the disorder progresses sym p toms become more frequent or constan t .
Assessmen t a n d e xa m ination o f suspected c a r pal t u n ne l sy n d ro me sho u l d always be done w i t h a high index o f susp i c i o n c o n cerning
the cervi c a l spine . N e c k p rob l e ms com m o nl y can rad i a te sy m p toms into the hand in a s im i l a r distri b u tion . It i s likely that if attention IS n o t paid to possi b l e c e rvi c a l i nvolvement c a r p a l lUnne l can be
mistakenl y diagnosed . Ta pping fi r m ly over the ca rpal t unn e l (Tine l 's sign) and s u s t a ined
fu ll passive WTist flexion (Pha lens test) a re sa id to provoke t he pa ti e n t s '
sy mpto ms and to be d i agn o s t i c o f the d iso rder. H o w e v e r these tests ,
have only moderate p red icti v e value and the d iagnosis i s usually established on history-ta k i n g , althoug h numerous o l her tes ts exist (Szabo and Madison 1 9 9 2 ) . Use of a hand d i a gra m to reac h the diagnosis has been shown to have g o o d sensi tivity and speci fici ty ( Ka tz and S t i rra t 1 99 0 a ; Katz
et
a l . l. 990b) .
C O M M O N D I S O R D E RS
C a rp a l t u n n e l s y n d ro m e i s t h e m o s t fre q u e n t l y e n c o u n t e r e d peri p h era l c o m p ressi o n neu ro p a thy, a n d i s t h e second most common
i n d us t r i a l mJ u!)! in the US. Two types of p a t ients have been desc ribe d : the typ i ca l pa t ien t ,
m whom t he c ond i ti o n was first re cog ni sed i s a ,
woman o l d e r than 40 More re ce n tl y a se cond d i s tinct p opul a ti o n with t h i s p ro b l e m has b e e n recognise d - t h e y a r e w o rkers o f e i t h e r
sex who per fo rm repe t i t ive man u a l labour t h a t i n volves gri pping. S tu d ies have shown that o c c u p a t i o n a l risk fa c tors i n c r e a s e the
l ikelihood of deve l op i ng the c o n d i ti o n . Work that requires h e a vy w r i s t a c t i vi t y, re p e ti t i ve fle xion and e x t e ns i o n o f the wr i s t
,
finger
m o t i o n w i t h w r i s t e x te n si o n or exposure to v i b ra ti o n i s c o n s idered to b e hi g h risk Biome chanical studies have shown tha t i ntraca rpal p r e s s u r e is p a rt i c u l a rly exagge ra t e d by w ris t flexion a n d u l n a r deviation ( S z a b o a n d M a d ison 1 9 9 2 ; Sola 1 9 94) A l th ou g h o t he r systemic r isk fac tors exist s u c h as diabetes o r thy roi d d isord e rs , i t has been est i ma ted that up to 47% o f a l l c a s e s may b e c a u s e d by wo rkp l a c e fa c to rs (Bake r a n d Ehrenberg 1 9 9 0 ) Ty pi ca l l y those involved in s u s tai n e d or repe titive gras ping, ha nel/wrist acti v i ty or u s e o f v i b r a t ing t o o l s a re m o re lik e l y to su ffe r the d i s o rd e r . 1 nc rease d a ss o c i a ti o n in b u tc h e rs ,
w it h ca rp al t u nnel syn dro m e h a s b e e n fou n d
m e a t packers , checkou t workers , e l ec t ro n i c assem b l y
w o rke r s musicians , ty p i sts , c a rp e nte rs and garme n t workers (Ba k e r ,
a n d E h r e nbe rg 1 99 0 ; Mase a r e t al. 1 9 8 6 ; F e l d ma n e t al. 1 9 87) . S u ch
situati ons whe re i ni t i all y there a re in termittent symp t oms , a b a t i n g w i t h rest a n d r e t u r n i n g with sustained a c t i v i ty o f t h e hand and wris t , have b e e n d e fi ned a s dynam ic c ar pal tunnel syndrome ( B raun e t al .
1 9 89) Cont i n u i n g w i th the p rovocat ive acti v it y is l ike ly to cause
a
w o rseni ng o f s y m p toms and a d e te rio ra t i o n o f func t i o n . T h e syn d rome is also associated w i th pregnancy - i t is the second most fre q ue n t muscu loskele tal symp tom of p regnancy a fter back p a in
.
It us u a l l y occ u rs i n th e seco n d a n d third t r i m este rs , a n d a rises Crom
lluid re t e nti o n and swe lling. Wrist splints are very effectiv e , a n d when wo rn a t n i ght frequen tly bring relie f The symp toms vi rtu a l l y a lways res o lve rapid ly a ft e r d e li v e ry, a l t h ou gh t h e y may re cu r d u ri n g subsequent pre gna ncies (Heckman a n d Sassard 1 994) . O ther diseases and condi t i o ns may be i n v o l v e d in the p a thogenesis o f c a rp al tunnel syn d rome (Szabo a n d Mad ison 1 9 9 2 )
226 1 C !-l A r T E R T E N
T H E H U MAN E X T R E M I T I E S : M E C H A N I CA l D I AG N O S I S & T I I E RA I' Y
N a t u r a l h i story
The patho physi ology of carp a l tu nne l syndrome re l a tes to a l tera tion of p ressu res due to changed flu i d
and tendon d yn a m i c s l e a d i ng t o
ischaemic i mp a i r m e n t o f the n e rve ( S z a b o a n d G e l b e r m a n 1 98 7) Pre ssure within t h e c a r p a l tunnel i s marke d l y e levaled i n t hose wi th the synd ro m e pre-ope ratively com pared w i th control p a t i e nts a n d
p o s t - o p e r a tive l y ( G e l b e r m a n e t a l . 1 9 8 1 ; O ku t s u e t a l . 1 9 8 9 ) Pressu res a re i n c reased b y moveme nts o f t he w rist a n d loca l m u scle c o n tractions ( Sz a bo and Chidgey 1 9 8 9 ; We r n e r e t a l . 1 9 83) L i k e m a n y o ve ru s e c o n d i t i o n s onse t i s gradu a l , sym p t o m s be ing initi a l l y i n t e rm i ttent a nd m i l d ; the pa thology is re versible I t is t h o u gh t
t h a t continued a ggra v a t i o n eventu ally p rod u c es i r revers i b l e c h anges .
Continued press u re and re d u ced c i rc u l a ti o n p ro d u ces o e dema a n d fur ther s w e lling . N e rve c o n d u c t i v i t y i s fU rLh e r imped e d a n d w i t h o u t relie f these changes may p ro d u ce e x t e n s i v e i n t r a n e u ra l fib rosis (Su n d e rland 1 9 7 6 ; Ge l b e r m a n e t al. 1 9 8 7 ) . As the c o n d i L i o n w o rsens ,
sym ptoms become constant , motor i m p a i r m e n t deve l o ps and gross mo rphological changes may be fo u n d in t h e med ian n e rve . At L h i s p o i n t s y m p toms a re no longe r re vers i b l e a n d su rg ic a l re le a s e o f the transve rse c a r p a l ligamen t may be n e cessary to b r i ng re tid, a l though
t h i s is n o t always s u ccess fu l (Szabo a n d Madison 1 9 9 2 ) M a n agement
P a tients may p resent w i t h carpal t u nne l s y n d rom e e i th e r at t h e i n fl ammatory o r chro nic s t a ge . The former w i l l u s u a l l y have co n s t a n t sym p t o ms , whi c h are easily agg r a v a ted o r p ro d u c ed At the c h ro n i c
s tage pa tients may presen t with a d y s fu n c tion o f the m e d i a n n e rve , wh ich pro d u ces intermittent symp toms w i t h a c t i v i ty The distinc t i o n
be t w e e n t h e t w o s h o u l d b e cl e a r fro m the h i s t o ry, b u t c a n b e c o n firme d by their re s p o nse to re p e a l e d e x t e nsion o f l h e w ri s t w i t h e l b o w e x tensi o n . This m a n o e u vre s t retches t h e n e rve ancl i s l ikely t o worsen a n i n fl a m ma tory c onditi o n . I f a dysfu n c t i o n i s p rese n t the stre tch should re pro d u c e the sympto ms , re p e t i t io n sho u l d not wo rsen the s ym p t o m s , and these shou l d a ba te once t he s t re t c h is re lease d .
D u r in g the inflamma t o ry s ta ge the rapy has l i t t l e t o o ffe r. Use o f a
wrist splint at n ight and d u ring agg r a v a t ing acti v i t i es , a n d avo idance of a g g r a v a t i n g a c t i v i t i e s m a y h e l p .
As
noted
above
the
p a t h o p h y s i o l o g y i s a m i x t ur e o f m e c h a n i c a l fa c l o rs c a u s i n g physiological ch a nges - cessa tion o f fa c tors that are c learly aggrava t ing the cond i tion may p revent pro gress i on Av o i dan c e of extremes o f
C H A P TE R T E N
w ri s t ne x i o n s ,md e x t e n s i o n c a n ease s y m p t o m s a t any s t a ge o f t h e d is o rci e r, a n d th is is most effectively a c hieved w i t h the use o f a w rist s p l i n t . A two - we e k t ri a l o f w ri s t splin t
u sage
is t h e re fo r e a l ways
j us t i Cie d . Tne m o re a d vanced the pro b l e m is , the l e s s llkely s i m p l e c o n s e r v a t i ve m easu res a re to
b e e ffe c tive . I llJ e c ti o ns o f c o r t i c o s t e ro i d
a p pe a r o n l y to h e l p i n t h ose wi t n
mi
l d e r sym p to ms , t h a t is t h o se
w h o n a ve had t n e c o n d i t i o n fo r less t nan a yea r with d i ffuse and inte rm i n e n t s y m p t o m s and no wea kness or a tr o phy Those a t a mo re
i1 d v a n c e d p a l n o l o gi c a l s tage w i th m o re seve re s y m p t o ms o n l y gain te m p o rary re l i e f and su ffer a very high re l a p s e rate follo'vvi ng inj e c ti o ns
( G el be rmi1n
et
a t . 1 980)
[ f a dys l-u nc t i o n is p rese n t , s tre t c h i ng five t o te n t i m e s seve r a l times a day s ho u ld be sta r te d . Show t h e p a t i e n t how to lean o n t o a table k e e p i n g t ne e l b o w e x te n d e d , then lean fo rwa rd p r o d u c i ng wrist
e x te ns i o n s u lli c ie n t l y t o p ro d u c e t h e i r sym p to m s . A s l o n g a s t h i s d o e s no t wo rsen t h e cond i t ion and a ll symp toms go o n c e the s t re t ch is re l e i1se d , the e xe rcises may be in creased to e v e ry c o u p l e o f h o u rs .
I f t n e s t re t c h u s i ng wrist i1nd elbow e x tension ne e d s t o b e progressed , i1
m o ve m e n t th a t fu rth e r t e nsi o ns neural stru ctures i n the arm such
as u p pe r limb t e n s i o n t e s t o ne ' ( B u t l e r 1 9 9 1 ) c o ul d be c o nsi d e re d .
It i s i m p o rtan t to u s e s u c h m a n o e u v res t h a t
i nduc e
sy mp toms by
s tr e tc h i n g t h e n er ve and ca u s i ng i s c haemia w i t h g re a t care. Pbotos 78, 79 Carpal tu n n el .'Tlldro me dJ'.'./unction. Place t h e affected h a n d o n a ta ble (mdflatten with pressure from t h e other hand Keeping the "Ibm.!' in extension, lea n forward ooer the table so that tbe wrist isfulI)' ex/ended, and the n 1I'11bdrtlll' 1 0 the starting position. Stretching o r paraesthesia sho u ld be provoked, which s u bs ides a s the starting position is resli med Tbis ca n be repeated up to ten tim es, as long as symptoms are not lastingly aggrCII 'ated
78
79
1 227
228
1 C H A I'T E I1. T E N
T H E H U ,v' A N
E X TR, E M I T I ES:
M E C H A N I C A L D I A G N O S I S & T H E RAl'Y
Tenosynovitis - de Quervain's Syndrome ('trigger finger ' ) Various t e n d o ns o f t h e
h a nd a n d fore a r m are p r o n e t o d e v e l o p i n g
i n flamma t o ry con d it i o n s
.
Cumula tive m i c ro - fa i l u re d ev e l o ps as a
r e su l t of overuse and p ro du c es swelli ng o f t h e tendo n , t h i c k e n i n g and s tenosis o f tend o n sheath s , fib rocy te p ro l i fe ra t i o n a n d adhes ions T hese changes ca u se occlu s i on o f b l o o d flo w and i n te r r u p t i o n o f n o rm a l d i ffusion s o th a t t h e tissues are de p r ived o f n u t r i enLs re qu ir e d fo r re pair and
h e a li n g (Tho rson and S z a b o 1 9 9 2 ) Te nd ons
can
d e v e l o p a swelling o r n o d u l e which ca uses ca tch in g t r i gge r i n g o r ,
locking o f the digi t , re ferre d to as s te n os ing t e n os yn o v i t i s o r 'tri gg er fi nger' ( N ewp ort et a l . 1 9 90) These u p p e r e x t re m i t y te n d on i tis e s
a re fre q uently the r esu l t of cumula tive tra u m a due to re p e tit i v e motion
t h a t overwhelms the n orma l re covery of t issues fro m ac t i v i t y - t h e re is thus frequently an o c c u p a t i o n a l ele m e n t in t he p a t h o ge nesis o f th e se con d i tions (Tho rson a n d S z a b o 1 9 9 2 ; Yassi 1 9 9 7 ; S o l a 1 9 9 4 ) Ta s k s i n v o lv i n g h i gh
handwo rk c on s t i tu t e
l e ve l s o f fo rc e a n d re pe t i ti o n o f m a n u a l
a consid e rable risk
fa c t o r fo r d e v e l o p i n g h a n d
w r i s t tendonitis ( A rm s tro ng et al. 1 9 8 7) This
p ro b le m may a ffe c t a n y o f the te n dons c ross ing t h e w r i s t , b U l is
p r oba bly m os t c om m on l y seen in the a b d u c t o r p o l licis l o n g u s a n d
extenso r p o l l i c i s b rev i s te n d ons - a c on d i t i o n known a s d e Q ue rvain's Syn d ro m e ( Th o rs on a n d Szabo 1 9 9 2 ) The re is p a i n in the w r i s t and p ro x i m a l t h u m b a re a , w i t h m a r k e d te n d e r n ess o ve r t h e rad ia l st y l o i d process Resisted ab d u c t i o n ancVo r e xten s i o n o f the t h u m b a re pai n l u l
a n d we a k . U l n a r d e v i a t i o n , e s pe c i al l y w i t h the t h u m b i n f e x i o n l
(Finkelstein's test ) , is p a infu l a nd l i mited - t h i s manoe u v re s t re tc h es th e a fl'ected ten d o n (Thorson and S z ab o 1 9 9 2 ; S o l a 1 9 94 ; Witcza k et
al. 1 9 9 0)
M anage ment
Recommended manage ment o f this type o f c o n d i tion us u a l l y inc l u d es spl i n t ing res t , N S A l D s a n d inj e c t i on o f c o r t i c os te ro i d s (Sola 1 99 4 ; ,
Tho rs o n a nd Szabo 1 9 9 2 ; Wi tc z a k e t aL 1 990) [n fact , s pl i n t i n g b y
i tse l f i s m u c h less successfu l tha n i nj e c t i o n w h i l e ,
a lo ng h is t o ry o f
t h e con d i ti o n c a rries a p o o r progn O SiS even w i t h inj e c t i o n s (We i ss e t
aL 1 9 9 4 ; N ew p o rt
et
aL 1 9 9 0 : Rh o a des
et
a J 1 9 8 4 ; Witt
et
a l . 1 9 9 1)
Su rgic al rele ase is rec o m m e n cl e d if c o n se rvative t re a t m e n t s fa i l
There a re n o stu dies i n d i c a t i ng t h a t mec ha n i c a l t h e ra p y may he l p w i t h th is prob l e m , H o wever, s u i ta b l e a d v i ce c o ncerns re la t i ve res t ,
C H A PT E R T E N
C O M M O N D I SO RD E R S
espec i a l l y early o n , fo l l owed by a functional re ha b ilitation a ppro a ch in v o l v i n g gra d u a ted resisted e x e r c i s es and s t re tches to a ttempt to n o r m a lise the im p a i red functi o n or the tend on . This would i n v o lve
res isted thumb a b d u c ti o n and lo r exte nsion a t a load tha t gen e r a t e s sym p t o m s w i t h o u t aggravating the m . Stretches m u s t be d o n e w ith
c a re and s h o u l d s tart with s e p a r a t e ulnar devia tion of the w rist and L a t e r t h e s e c a n be c o m b i n e d , w h i c h p l a c e s
t h u m b fl e x i o n
cons id e rable s t re tc h o n the a ffe c t e d tend o n . P/)oto 80
Se(ftlpplied isometric thu m b extensio n w itb compression.
To
be
perform ed lit
a
Jo r a m o m e n t, relax,
rh)'tb m ical pace - pressure on, hold and tiJen repeat up to ten times.
Pboto
compression. To be peljonned a t a rhytb m ic a l pace -
pressure on, hold J01' a m o m e n t. relax. and then rep eat
up
80
81
Selfapplied isometric tb u mb abduction with
to ten times.
81
Photos 82, 83 Ea rly tension lI/ o / 'em e n t jiJr tiJum/) extensors. witb wrist in neutral. Tb e p a tie llt starts lI'ilb Ibl! l/rm relaxed Oil a supporting swjace with the Ihumb up ,-ig b t (82). Tbe IhwnlJ is stretcbed in jlexion as Jar as p o ss ible, then relaxed to the starting pos it io n 7(} lYe repeated up to ten tillles. Gradually tbe patien t sbo uld in crease the m nge oj n U J I 'e m e n t u n til a ble to touch tbe distal end oj th e Jiftb m eta ta rs al (83),
82
8. '>
1 229
230
I C H A rT E R T E N
T H E H U M A N E X T R E M I T I E S : M E C H AN I C A L D I A G N O S I S & T H E R A I' Y
Pbotos 84, 85
Late,' te ns io n
lb umb extensors and abductors, i n cludin}!. H ','isl uln a r starls witb tiJe forearm relaxed on a supporl ing smjace, witb fiJe wrist and IJand O/Jer the edge and in neutral (84), MOl 'ements into u ln a r deviation, witIJ the tiJumb resting o n Ibe indexfingel: ca n be done in lIddil ion 10 rega in ing thu m b flexion, Later tlJe two Inoue m e n ts can be co miJined, so (ba l el'enlually witb tbe tb u m b in fleXion tlJe palie nt is also a ble to mOI'e inlo ulnar deuialiol1 (85) m o vem ent for
deviation . Tbe p atie n t
85
84
I f a p rogression is needed the thu mb o f t h e oLhu hand can be u s e d
to prov i de compression on the tender te nd o n while t h e p a tie n t a c tively flexes a n d exten d s t he a ffe c t e d t h u m b , H t h i s c a uses aggravati on of sy m p t o ms , m o de rate the e xe rcis e regime u n t i l this has subsi ded PIJotos
86, 87
in de Querflil in 's 5�l'nd/,() l I 1e, AP/)i)' jJressure witb opposite th um b on tender area of lendo n. Wh ile lIIaillla i n ill/!. cO I l /pression, tlJe jJalient flexes and extends tlJe tlJumb ten tim es, Compression during actil !e Itll)l'emenl
86
87
C O ,vl M O N D I S O R D E R S
C H A PT E R
I f a t r i gge r li nge r is p rese n t , ge l the p a tient to place the other t h umb as c lose to the n o d u le as possible and a p p l y constant p ressure . They should l hen re peate d ly flex and extend the a ffected digit so t ha t the n o d u l e kee ps pass i n g beneath the p ressure of the thu mb . Once this has made m o ve m e n t easier, ac tive movements should be done to m a i n t a i n improveme n ts Pholos 88, 89 Compression during acti ! 'e mOl!emeut in 'trigger finger' offiftb digit. Place tbe oliJer tbu lIlb on the affected area as close to tbe nodule as practical. WlJile In ail l ta i l l ing consta n t compression, j1ex and extend aI/fingers, running fiJe nodule u n der tbe presslire of tiJe thumb ten times.
88
89
Dupuytren's Contracture Th i s c o n d i tion i n v o l ves a pa inless t hickening a n d c o n trac l u re o f the p a l m a r fascia d u e to fi b rous proli ferati o n , which resu l ts in nexion de fo rm i t ies and impaired fu nctio n . Men are more commo nly a ffec ted
than w o m e n , w i th the inc i d ence i n c reasing progressi vely a fter 40 yea rs of age . S i m i l a r c o n d i tions can occur in the plantar fascia
The con d i ti o n may o c c u r u n i l ateral ly o r bilatera l l y ; the ring fingers a n d l i l tle fi ngers are most commo nly in volve d , the middle and i n d e x fi nge rs l e s s o ft e n The p a l ma r fa scia thi ckens and shrinks ; nodu l e s , ad hesions a n d c o n t ractu res d evelop ; the palm i s pu ckered a n d thi ck , and s u b cutaneous c o rd s may h o l d the fingers in flexion . The disorder p r ogr e s se s but a t a variab l e and u n p rediCl'able ra te . As i t progresses ,
flex i o n c o n t rac t u res l i m i t the m ovement and func tion of the hand . Exte n s i o n o f t h e fin ge rs b e c o m e s i m possi.ble , the gri p is impaired , there is di ffi.c u l t y letting go o f obj ects and the bent fingers b e c o m e a nu isance CApley 1 9 8 2 ; Berkow 1 9 8 7)
TEN
1231
232 1 C H A PT E R T E N
TH E
H U MAN E X T R E M I T I E S :
M E C H A N I C A L D I AG N O S I S & T H E RA PY
Photos 90, 9 1 Stretch fo r Dupuytren 's Co n tracture. With the otber thumb towards /be e n d of the fingers, slretcb inlo extension ten Urnes strongly enougb 1 0 jJrouoke {( b u rn ing sensation 'No burn no good: -
91
90
M a nagem ent
Gene rally o perative management is all that is consi d e re d : h o w ever Cyriax ( 1 9 82) suggested self-ma nagement by the patlent i n vo l v i n g
daily stre t ches to el ongate the fascia and mail1la i n e x t e n s i o n i n t h e early s tages o f the c o n d iti o n As i n o t h e r s o ft tissue con t rac t u re s , a n .
e a r l y a n d regu l a r s tre t c h i n g p r o gra mm e i s p ro b a b l y L h e b e s t management . The sym p tomatic re s p onse expected w o u l d b e t h a t o f
a dysfu nction - pain p ro d u ced o n s t re t c h i n g w h i c h a b a tes when L h e ,
stretch is relaxed . Using the opposing thu mb and i ndex fin ge r L O g r i p tbe a ffected d igits , the fingers sh o u l d be s t re tched out in to e x t e nsion ten t i m e s , t h ree o r fou r times da ily This shou l d be increased t o every two h o u rs a ft e r a
fe w days . To be o f v a l u e the s t retch needs to p ro v o k e
a
b u rn i n g
sensation i n the a ffected area . C o mm i t m e nt t o t he progra m me i s vital 'if the p a t i en t is to prevent progress o f the cond i tion o r reve rse it.
Bursitis T h i s term re fe rs to c o n d i t io n s i n v o l v i n g a b ursa , s u c h as t h e
t rochanteric , subacromial or prepatel lar, and denotes a n i n fla mmatory problem . At the sho u lder acute and c h ronic subacro m i a l b u rsitis is c o mmonly d i a g n o sed in a b o u t a third of p a tients viSiting gen e ral
practice ( van der Windt
et
al. 1 9 95) H o w e ve r o t h e r a u t ho rs d o not
re fe r to this d i a gno s i s and ,
,
in
phys iotherapy c l inics the prev a l ence
C H A I'T E R T E N
COMMON D I SO R D E R S
w o u l d s e e m fa r l e s s ( L i e s d e k e t a l . 1 9 9 7 � P e l l e c c h i a 1 9 9 6 )
Troch a n te r i c b u rsitis i s s a i d t o b e a c o m m o n cause o f l a teral thigh pain (Li t t l e 1 9 7 9) , es p e c i a l l y in p a t i e n ts wi th rh euma toid a r th ri tis
(RA) (Raman and Haslock 1 98 2 ) l l iopsoas bursitis has b e e n rep o r t e d i n p a t ie n ts wi t h RA a n d OA ,
with
( U n d e r w o o d et a l . 1 9 8 8 )
a n ing u i n a l m a s s a n d leg swel l ing
H o w e v e r , p a t i e n t s w i th p u t a tl v e
' t roc hanteric bu rsitis' a re fre q u ently misd i agnose d ; the i r symptoms
a re i n
fac t d u e LO lumbar spine p ro b l ems (Trayco ff 1 99 1 ) . Pre -patellar
b u rs i t i s , associ a te d w i t h considerable knee ling a n d conseq uently
re fe rred to as 'housemaid's k n ee ' , is m o re obviously recognised . Pai n , te n d erness a n d swe l l ing are l ocal ised t o t h e s i t e of t h e bursa , a n d are nowad a ys m o s t comm o n l y found i n c a rp e t layers (Eva ns 1 9 8 6 ) Generally t re a t me n t o f bu rsi tis i nvo l v e s
injection o r surgi c a l i n cisi.on ,
a l t hough t he bene fits have never b e e n e v a l u a te d . T h e re i s l i m i te d i n fo rm a t ion ab o u t b u rsi tis and i t s p resentation is vague and u nre l i ab le I ts n a t u ra l h i s t o ry is cons e qu e n t l y uns t u d ie d , a n d the best m a n agement is unknown . It is fr e q u e n t ly a diagnosis by exc l u s i o n of
other possi bilities .
A t i ts acu te onse t mechanical the rapy
is t o t a l ly ina p p ro p r i a t e - pain is cons t a n t and often e x t re me , and a ll m oveme nts a re b a r e l y tolera te d . Mechanical t he ra py cannot assist in these i n fla m m a t o r y co n d i ti o n s . H o wever, i f l a t e r the c o n d i t i o n b e c o m e s ch ro n i c and thus t h e p ro b l e m i s o f t issue dys function a n d ,
s e ns i t i s a t io n , a d v i ce o n a n a pp ropri a te gra d e d e x e rc i s e p ro b l e m may b e a p p ro p ria t e .
Overuse i nj u ries O cc u p a t i o nal o v e r u s e syndrome i s one t e r m u s e d to d e scribe p a in arising in v a rio u s pa rts o f the e xtremi ties a n d amibu ted to p o o r
workin g e n v i ro n m e n ts . These disorde rs a re also known by d i ffe re nt terms i n d i ffe re n t c o u n tries : re petitive s t r a i n inj u rie s , c u m u l a tive t r a u m a d i s o rd e rs , re p e t i t i ve m o t i o n d i s e a s e , o c c u p a t i o n a l cervi c o b rachial s yn d rome o r work-rel a t e d u p p e r limb disorders .
These te rms , a l though developed to explain occupational aches and pains , are e q u a l l y
appl ied to recre a tional and d omestic environments .
Re p e t i t iv e s t ra i n h a s b e e n a s s o c i a t e d w i th p l a y i n g m u s ic a l instruments , e l ec t ro n i c game s , knitting, solving Rub i k 's Cu b e and marathon runn i n g , as
well
as a wide range of industrial and clerical
j obs . T h e y a re u m b rella terms describing a range o f disord ers that d evelop as a resul t of re p e titive m o v e m e n t s and awkward posture s .
1 233
2 34 1 C H A PT E R T E N
TH E
H UMAN
E X T R E M I T I E S : M E C H A N I C A L D I A G N O S I S & T H E RA P Y
Suc h conditions are n o t new, and were fi r s t desc r i be d by Ramzz i n i i n t h e seventeenth c e n tury. However, there have been l a rge i nc reas e s in
their re p o r t i n g in Wes t er n c o u n t ries in the last fe w d e c a de s .
I n the
US th e re was a q u a d ru p l ing of the rate of w o r k - re la t e d repe t i tive
motion d is o rde rs bet ween 1 9 7 7 and 1 9 89 , so tha t t h e y con stitu ted 6 0 % o f a l l occupational i l lnesses i n 1 99 0 w i th an est i m ated c o s t o f c ompensation that exceeded $US20 b i l li on p e r y e a r ( L o uis 1 9 8 7 ; Yassi 1 9 9 7 ; Rempel
et a 1 .
1 9 9 2 ) Whe the r this a l a rm i n g r i se i s d u e t o
a l tered work p ractices tha t a re causing a n incre a se
in
pathological
cha nges, or rather i s due to greate r accessibil i ty to work co m pen s at io n and alte re d p a tterns o f soc i o-economic behavi o u r is u nkn own .
E rg o no mic hazards that are sa i d
to
pose a risk in the deve l o p m e n t o f
cu mula r i ve trau ma diso r d e r s (CTD) inc lu de rep e t i tive a n d f o rce fu l m o ti on s , s ta t i c m uscle l o a d i ng and m e c h a n i c a l s t r ess conce n t ra t i o n s , extre mes o f v ibr at i o n a n d t e mpera t u re , and aw kward a n d constra i n e d J o i nt p o s t u res . Risks a r e i n creased by c e rta i n o rga ni sationa l fac t o rs
a t work , such as excessive d u rati on or speed , e x ter na l l y paced w o r k (assembly l i n e producti o n) , i nad e q u a te rest peri o ds a n d monotonous tasks . Mult i ple risk factors i ncrease t h e r i s k o f CTD c o ns i d e ra b l y (Viikari-J u n t u ra 1 9 9 8 ; N o v a k a n d M a c k in n o n 1 9 9 8 ; Yassi 1 9 9 7 ; Rempel e t a l . 1 9 9 2 ; S i l v e rs t e i n et a l . 1 9 8 7) Wo m e n a re a ffe ct e d w i th
CTD a l most twice a s o ften as men ( D o h e n y
et
(I I . 1 9 9 5 )
Low-load m us cl e acti v i ty may be i nv o lv e d i n t h e ae t i o l o gy - t h i s d oes n o t i n duce t i redness as h i g h - l o a d m u scle w o rk d o e s , whic h
causes a na t u ra l c o nstraint in the activ i t y In s te a d the a c t i v ity can be main t a i ned fo r p ro l on g e d p eriods w i t h o u t , I ll l ti a l l y, awareness o f d i sc o m fo r t However, a t t h es e low loads metabo l ic concen trations i n t h e tissues are bei ng a l tered , so t h a t o v e r prol o nged per i o ds the
m u s c les b e c o me suscep tible t o n ec ro ti c c h a n g e s (S i o gaa rd a nd Sj o ga a rd 1 9 9 8)
The accumul ative fo rc e , w h i c h i s ge n e ra t e d b y
r e pe t i ti v e motion and susta i n e d p os t u res o v e r a prolonged period , i s t h o u gh t t o cause mi c ro - t e a rs a n d tra u m a to the s o ft t i s s u e s . ln flam mati o n , p ain and s w e l l i ng may ensue . A l t h ough a v a riety o f s o ft tissues have been im p li c a t e d , tendons a re a p r i me s o u rc e o f
symptoms wi th th e s e disorders . P a t h o l o g ical c hange s and s u b s e q u e n t occlusion o f bl oo d now combine to de pnve the t e nd o n a n d o t he r a ffe c t e d tissues o f t h e n u t ri e nts req u i re d fo r repa i r a n d hea l ing . D egenera tive c h a ng es in the t end o n and i m m a t u re repai r tis s u e would appear t o preve n t fu l l repair a n d e n co u r a ge pers i s t e n t symptoms
COMMON D I SO R DERS
C H t\ P T E R T E N
( R e m p e l e t a t . 1 9 9 2 ; T h o r s o n a n d S z a b o 1 9 9 2 ; Smi th 1 9 9 6 ; N erves are a l s o d a m a ge d i n re pe t itive m o tion
Lea db e t te r 1 9 9 2 )
p ro b le ms p re s en t ing a b ro a d spec tru m o f cha nges f ro m pe r i n eu ral ,
o e d e m a to axona l d e gene ra t i o n - change s which mi g ht t ak e many y e a rs to d e ve l o p (Novak and Mackinnon 1 9 9 8 ) . F ailu re to rec ti fy the excessi ve l o a d i n g on the s tru c tu res and to normalise the tissues m a y o v e rwhelm t he re c o v e ry ca p ab ility of o n e o r s e v e ra l o f these s t r u c t u res (A l l a n 1 9 9 8 ) The con d i t ion m a y b e c o m e progressi vely w o rse , p e rs i s ten t a n d ] [ revers i b le . CTD c a n oc c u r i n the hands , wrists , e lb o w s , s hou l d e rs , n e c k , b a c k ,
h i p s , k n e e s a nd a n k les Back p roblems a re the mo s t c o mm o n , b u t .
u p p e r- l i m b CT D s a re t h e fas t es t gro w i ng gro u p o f o c cu p a t i o nal d i s o rd e rs (Ya s s i 1 9 9 7) S pe c i fi c cl i n i ca l s yn d ro m e s t h a t a re inc l u d ed wi t hi n t he u m b re l l a t e r m i ncl u d e d e Q u e rva i n s ten osyno vi ti s ca rpal '
t u n n e l s y n d rome
,
,
t e n osynovitis , l a t e ra l and me d i a l e p i c o n d yl i t i s ,
ce r v i ca l s y n d ro me a n d ro tator cu ff te n d o n i t is (Yassi 1 9 9 7 ; Re m p e l e t
a l . 1 9 92 ) Some of these have already been d iscussed i n o t he r s e c t i o n s wh e re c1 e w i l e c1 d es cri p t io ns i nc l u d ing s u s p e c t e d o c c u p a t i o n a l ris k ,
fa c t o rs , w i l l be fo u nd
.
S u c h wo rk - re l a te d u p p e r li mb d i s o rd e rs
( W RU LDs) , wh i c h h ave rela t i vel y clear c l inical c h a ra c teristic s , have
bee n Le rmed Ty pe 1 cond i ti o ns (Hutso n 1 9 9 7) The t e rm Ty pe 2 W RULDs is used LO describe poorly d e fined region al p a i n synd romes ,
\-v i th
a sp r ea d
0 1' symp t o ms from t he n e c k to t h e h a n d t h a t have a
p ri me ne u roge n i C co m po nent I t is thought that pe riphe ral and ce n tral .
s e n s i t is a t i o n c re a t e s t h i s s t a t e o f p a i n a m p l i fi c a t i o n p ro d u c i n g re fra c to ry u p p e r l i rn b p a i n ( H utson 1 9 9 7)
S in c e t he t e r m s re p e t i t i ve strain inj ury ' , o c c u p a ti o n a l ove r u s e '
'
s y n d rome ' o r ' w o rk - ['e l a te d u p p e r l i mb disorders ' , e tc . h a v e been
coine d , p ains of p os t u ra l o rig111 have been c l a s s i fi e d as i nj u ry a n d in s o m e e x tre m e cases patients ha v e claime d p e rma nen t dis abili t y The p a t i e n t m a y go t h rough a rep e a t e d c y c l e o f re s t , re t u rn to wo r k , re c u rre nce o f s y m ptoms a n d re fe nal t o various experts that u ltima te ly
may e n d i n l oss o f work - u l t i m a te ly o n ly la wy e r s and he a l th care pro fess i onals be ne fi t (Yassi 1 9 9 7 ; Lo u is 1 9 8 7 ; Irela n d 1 9 9 8 ) The pan t h a t t hera p i s ts and p hysi c i a ns have played i n the lll c rease of the c o mp laint and its c hronic i t y is unknown S ome a u t h o rities , howe ver, berated the i r medica l co l l e agu es for the e p i d emic of re pe ti t ive s t rain i nj u ry w h i c h h i t Au s t ra l i a in the e a rl y 1 9 8 0 s . One called i t 'an i a t ro g e n i c e p i d e m ic o f si m u la t e d i nj ury' wh ose ps y chol o gic a l b a s i s w a s re v e a l e d by t h e ra p id rise a n d e q u ally ra p id fal l a few ye a r s la t e r
1 235
236 1 C H A PT E R T E N
T H E H U M A N E X T R E M I T I E S : M E C H A N I CA L D I AG N O S I S & T H E RA PY
in repo rting o f the c o n d i ti o n (Be l l 1 9 89) . l t is said t h a t t h e d e c line i n the problem came a b o u t with awareness that i t w a s a non-p hysical socio-po l i t i c a l p h e n o menon and a c o r r es po n d i n g l oss of pecuniary b e n e fits enj oyed by powerful vested i n te rests a nd b y su ffere rs O reland
1 998) . It is suggested that the re a re strik ing simi larities be tween t he Australian experience in the m i d-eighties vli t h repel l tive strain inj uries and t h e pres e n t e x p e r i en c e in the U S w i th CTD ([ r e l a n d
1 9 98)
Reports fro m b o t h A u s t ralia a n d the U S m a k e c l e a r t h a t howeve r ge n u i ne were the s y m p t o m s rep o rte d they t e n d e d to conce n t ra te i n certain a reas , while wor kers wi t h t he same task in a d i ffe re n t state o r c i t y were rel a t ivel y unaffecte d . P a t i e n ts w h o d i d p a rt i c u la rly b a d l y
in one o u tbreak w e re those w h o received me d ic a l tre a t m e n t o u ts i d e their workplac e , t hose who we re treated su rgica l l y a n d t h o se i n v o lv e d
in litiga t i o n ( H u s kiss o n 1 9 9 2 ; Hadler 1 992a) O v e r- m e d i calisa tion o f the d i sorder and failu re to encou rage p a t ient res p o nS i b i l i t y fo r t he
a p propri a t e behaviou r is c l e a rl y a fac t o r in the s p read o f t h is cond i t i o n . I t i s i m p o rta n t to reco g n ise that medical a u t h o r i t ies a re s t i l l ve ry d i v i d e d o n this issu e . S o me c a te g o r is e the more i n t a n g i b l e c o nd i ti o n s as p u rely psycho s o c i a l with the c a p aci ty to d e ve l o p i n t o e p i de mic proport ions i f s o encouraged b y l a wye rs a n d medics S o m e h n d n o evidence tha t l i nks these diso rders wi th occu p a t i o nal [ a c t o rs a l t h o u gh '
w o r k m a y a g g r a v a t e e x i s ti n g s y m p t o m s ( B a r r o n e t
,
Ci t . 1 9 9 2 ) .
A l t e r n a t ively e rgo n o mists a rgue that occu p a t iona l fa c t o rs h a v e
a
causative role in many of these conditions . A l t h o u gh e p idemiological data suggests a s s o c i a t i o n b e t we e n c e r t a i n o cc u p a t i o ns a n d t h. e development o f some o f these cond i t i ons , i t mus t be re cognised that associ a t i o n is no t causati o n , a n d that the t rue rol e o f b i o m e c h a n i c a l fa c to rs h a s n o t ye t been d e fi n i t ively answ e re d . O dl e r fac t o rs t h a t may h a v e a ro le in the d e v e l o pment a n d re po r t i n g o f sym p t o ms s u c h as leisure a c t iv i t i es , i n d i vi d u a l fac t o rs , gene t i c p re d is p o s it i o n , t he de gree to wh ich ind i v iduals wo rry o v e r n o rm a l a ches a n d p a i n s , J o b satisfa c t i on a n d other sociocu l t u r a l fac t o rs a re rare l y incl u ded i n t h e a nalysi s . M o s t studies a nal yse a p o i n t i n t i me ; d isease c a u sa t i on is best examined by s tu d ying a coh ort of a sym p t o m a t i c ind i v i d u als
over time t o see who deve l o p s the disease of i n t e res l . These s t u d ies a re lengthy, complicated a n d considera b l y m o re c o s tly. T h e re has b e e n no w o r k tha t a d d resses d i ffe re n c e s i n p re v a l e n c e 0 1 t hese c o n d i t i ons be tween those 'v\l o rk ing and not w o rk i ng - it is certain ly not the case tha t those who a re n o t i n fu ll t i m e e m p l o y m e n t a re fre e -
o f these m usculosk e l e t a l c o m plain ts .
C H A PTE R.
C O M M O N D I S O R D E RS
An exa m p l e o f t he i mpo rtance o f sociocultu ral fa ctors was observed a t M c Ke n z i e 's We l lington Physio the ra py Cli n i c b e fo re and a fter
1973,
wh i c h was t he year o f t h e i n trod u ction o f the Accident Rehabilitation
and C o m p e ns a t i o n Act i n N ew Zealand . T hi s A c t covere d the e n t i re
p o p u l a t i o n 3 6 5 d a y s a year ( w o r k i n g or n o t ) a g a i n s t i n j u ry by
acci d e n t Two y e a r s be fore t his d a t e , 6 3 % o f p a ti e n ts re p o rted that
t h e i r s y m p t oms started fo r no a p p a re n t reaso n , whereas two ye a rs a ft e r t h i s d a t e , 6 9 % a t t r i b u t e d t h e i r p ro b l e m t o an a c c i d e n t . Th ro u g h o u t t h i s p e ri o d a b o u t 5 5 % o f p a ti e n t s w e re i n p a i d
e m p l o y m e n t ( u n p u b l i sh e d d a ta , Wel l i n gt o n Ph ysio t h erapy Clime
patient re c o rds) Once i n d i vi d u als deve l o p p a in t h ese sy m p t o ms may b e wo rsened by
o c c u p a t i on a l a c t iv ities , but this d o es n o t mean tha t th ese a c tivi ties have c a u s e d t h e m . S o c i o econ o m i c factors such as how p e o p l e a re p a i d w h e n t h e y a re ' s i c k ' and the i nfl u en c e o f lawyers and tra d e
u n i o n i s ts may e n c o u rage su ffe re rs t o a t trib u te d i s e a s e c a u s a t i o n to occ u p a t i o na l a c t i v i ties w hen there may be no absol u te p ro o F Fo r this The i n a b i l i t y of ' s i c k p a y ' systems and wo rkplaces to enco urage a gra d u a l re tu rn t o normal activities does n o t help t o clari fy this con fl i c t o f i nt e res t . The ro l e o f h e a l t h care profeSSionals in t his is a m b iguous A re d i s a b i l i t y, work a v o i d ance a n d blame e n c o u r a ge d , h o we v e r u n w i t t i ng l y, w h e n r e s t from a ggrav a t ing activ i ties , wh ich a re s e e n a s t h e cause of the i r p roble m s , a re c ondoned? D o e s denial o f t h e pa tien t's
p ro b le m , as i t l a c ks a cl ear pa t h o logic a l basis , only exaggerate con fl i c t b e t w e e n 'the syste m ' a n d the p a t i e n t ? This a rea is very c o m plex and i t is p rob ably bes t , a t th is p o i n t in t i m e , to recognise that the evidence concer ning causa tion is u n c l e ar. Management of overuse injuries
The re is
a ge n e ral c o nsensus that e a rl y d ia gnosis a nd i n te rventi o n
i m p ro v e s the prognosis o f these pro blems CYassi 1 9 9 7 ) . T h e m o re t i me s ym p toms have pers i s ted , the more times the p a tient h a s been through the rest/re t u rn to work/recurrence cycle , then the more lik ely it i s t h a t the p a t ho l ogy
will h ave p rogresse d t o being irrevers i bl e .
The success rate ove r t h e years fo r e i the r conservative o r s u rgica l t re a tm e n t for these d i s o rd e rs has been , a t best , only fa i r (Blair and Bear- Le h m a n 1987) The ergo n o m i c c o n d i tions a t the w o rkplace , wh ich may genera te t hese p r o b l e m s and probably aggravates t he m , needs to be a d d ressed .
TE N
1 237
238 1 C H A r T E R T E N
T H E H U M A N E XT R Elv\ I T I E S : M E C H A N I CA L D I A G N O S I S & T H E RAI' Y
Failu re to a l t e r fa u l t y tasks or p o s t u r e s w i l l si m p l y l e a d to t h e recu rrence o f p roblems a s s o o n as t he e m p l o yee re tu rns to wor k . Particu l a r aspects o f work t h a t shou l d b e a d dressed b y e rgonomic i n t e rventi o n s a re re p e t i tive n e s s , fo rce/me c ha n i c a l s t ress , p o s t u re , v i b ra t i o n a n d psychos o c i a l stresses . Red esigning worksta t i o n s a n d t o o l s can be an e ffective means o f re d u ci ng t h e ris k [a c t o rs fo r CTD (Yassi 1997) Wo rk o rganis a t i o n o ught t o be add ressed also so tha t th e worker is a b l e to take s u ffic ie n t res t b re a k s a n d ro tate various tasks . However, the re sp o n s i b i li ty is also o n the w o r k e r to ma i n t a i n a ppropri a t e p o s t u res , c h a n ge p o s i t i ons fre q u e n t l y and pe r fo r m tasks in t h e least s tre s s f u l way. A l l p a ti e n ts w i l l need t o b e g i v e n
an
u nd e rs t a n d ing of these issues as they pertain to t he i r i n d iv i d u a l ci rcu ms t a n ce s . I f w o rking c o n d i ti o n s a n d t i m e t a b l e s c a n n o t b e ameliorate d , t h e p rognosi s i s fre q u e n t l y b l e a k Ra n ge o f movement and s t re t c h ing e x e r c i s e s s h o u l d be i nt ro d u c e d to p revent sta t i c p o s t u res a n d fac i l i t a te i n t e rru p t i o n o f t a s k s Postures need to b e a l te red t o pre v e n t c o ns tra ine d , a w k w a rd l o a d i n g that causes s tress concentrations o n certain tiss u e s . I f s p e c i ric t e n d ons a re i m plica ted then exercise progra m mes t o s t re ngt h e n. a nd s t re tc h s ho u l d b e u s e d to try to norma l i s e [u ncti o n . I t i s the c l i n i c i a n 's responsibility to provide a p p ro priate i n l'o rma tio n t ha t add resses t h ese issu e s . However, i t is only the p a t ie n t who is a c t u a l ly a b l e to p u t them i nto prac tic e . The e ffect iveness o f such exerc i s e p ro g r a m m e s is uncl e a r. A one -year s t u dy fou n d that two daily seve n - m i n u te exe rCIse b reaks had no e ffe ct o n decreaslOg neck and u p pe r l im b sy m p toms ( S i lve rstein e t al. 1 9 88) . S p l i n ts , N S A l D s , p h ys i o t h e r a p y m o d a li t i e s a n d c o rt i c o s t e r o i d inj ec t i o n s a re re commended inte rve n t i on s ( Yassi 1 9 9 7 ) H owever, there i s l i t t l e e v i d e n c e t h a t t h e s e can s u c c e ss fu l l y t re a t t h ese c o n d i t i o ns . For more d e ta i l s e e ind i vi d u a l c o n d i t i o n s d iscusse d else where in t h is chap ter.
'Groin strain' or adductor strain Muscle-te nd o n s t rains in the gro i n a re a a re n o t unco m m o n s p o rts inj u ries (Galasko e t al . 1982) . These most c o m m o n l y involve a d d u c t o r longu s , re c t u s fe m o ri s , rec t u s a b d o mi nis o r i l i o pso a s , and a re o ft e n c h ro n i c b y t h e t i m e t h e patient see ks he l p (Re nstro m 1992) P a i n i s l o c a l i s e d t o t h e gro i n , b u t pain i n t he gro i n c a n have many O l her
C H A I' T E R T E N
C O {'vl IvI O N D I S O R n F R S
causes ( Re nstro m 1 9 9 2 ; M uckl e 1 9 8 2 ) Adducto r strains are p robably seen m os t c o m rn o n ly, and their manage m e n t will be described . P a i n w i l l be e li c i ted on resis ted a d d uction a n d passive a b d u c tion o r the FA B E R ( fl e x ionJab d u c t i o nJexternal ro tation) p osition - these
s t re t c h e s w il l b e re d u c e d in range c o m p a r e d LO t h e no n - inj u red s i d e .
T b e re may o r m a y n o t be ten d e rness to palpa t i o n . There may be
pain
a t re s t ,
d e pe n d ing on the stage o r d u r ing o r a fter activity, and
sti ffness m ay b e re p o rted (Renstrom and Peterson 1 9 80) . I n the acute stage rest i s fo llowe d by a gen t l e p rogressive exercise regime If poorly managed i t i s e asy fo r these i nj u ries to b e c o me chronic , when they become e x t re m ely d i ffi cu l t to t re a t (Renstrom and Peterson 1 9 8 0 ; Ren S l ro m
1 99 2 )
Once they h a v e become chro n i c , re turn t o ful l
p h y s i c a l a c t i v i ty can b e considerably d e l ay e d - many a re n o t fu l l y fi t fo r five mon lhs (Renstrom a n d P e t e rson 1 9 80)
l y p i ca l l y the p a t i e n t will give a his l o ry or i nj u ry incu rred playing I"o o l b a l l o r w h il e h orse ricl i n g , o r sy m p toms may begin inSi d i ously
T he y may have re s ted i n i tia lly a n d the inj u ry a p p e a re d to resolve , b u t e a c h t i m e t h e y re turn to the fo o tb a l l pitch it is re - a ggrava te d .
T h e e x L ra (' xer t i o n provokes a constant ache fo r then s e l l i e s to
an
a fe w d a ys , which
i n t e rmi ttent ache. f o l l o w ing each at temp ted re t u r n
Pholos <)2, <)3 A ddu clor slrelc/) ill sian ding Here tbe left leg is Ixing worked o n. The feet sbot/iel be al rigbl angles to each atbel; witb legs astride (92). The palielll tbell lunges o nto Ibe /lo n-injured leg, slrefcbing Ibe adductor region (93),
92
93
1 239
240 I C t-IAI'TER T E N
TH E
H U MAN
E X T R E M I T I E S : M E C H A N I C A L D I AG N O S I S & T I-I E I ( M Y
Photos 94, 95, 9 6 A dductor streich i n sitting, which generates m o re tension. 'l lle palienl sl(l ris with the soles of their feet togethe,; their bands resting on Iheir kn ees. lu/1ich (Ire ra ised. and tbe legs relaxed (94). They p ush tbeir knees towards the POOl; generating tension in tbe groin region (95).Alternative(J' overpressure can be ,�e n eraled I�)' Ibe pressure of the elhoUis upo n the k n ees (96). This stretch allo ll's an eas)' cOJrlj)ariso n to be made between the injured and non-injured side.
95
94
96
to sp o n t h e s a m e s t o r y is re p e a t e d
This h ist o ry o f rest , t h en
inadequate rehab i l ita t i o n , and return to a c t i v i t y that p roduces re inj ury does n o t facili tate matu ration o f t h e i nj u red tissu e , and the
se l f- p erp e tua ting
v ic i o
u s cycle of a chronic cond ition is p ro d u c e d
(G ross 199 2 ; R e n s t r o m and Peterso n 1 9 80) G roin s t rai n s a re rarely seen as acute condi tions; chro n i c problems a re
m o re
likely, in w h i c h
dysfun c t i o n is the main p ro b l e m w i th th e tissu e sens i t ised a n d decondi tioned to no rm a l use . M a n ag e m e n t a n d self-treatm e n t exerc i ses
If seen d u ring t h e a c u te phase , management i n v o l ve s t h e RICE pro tocol fo llowed b y gradual progress ive e xe rc ises i nvolving lo a ding in t o res istance and t o encourage tensile strength . See Treat Yo u r O w n
C O M M O N D I SO R D E RS
CI -I A I ' T m
S t ra i ns, Sp ra i n s a n d B ru ises ( Li nd s a y
et
al. 1 9 9 4 ) fo r d e t a i l e d ea rly
mana g e m e n t
[ f s e e n later t he p a ti e n t s l'lO u l d be t o ld o f th e l engthy p e r i o d o f re hab i li t a t i o n re q u i re d t o r et u rn t h e tend o n to fu ll function. I f s p o r t i n g
a c t ivi ti e s a re cau s i n g a lasting aggrava t i o n of sym p toms th ese s h o u l d be tempora r i ly a vo i d e d w h i l e rehabilita tion ta kes p l a c e (Gross 1 9 9 2 )
T h i s sho u ld sta rt w i t h is o m e t ri c c o n tra c t i o n s a n d stretche s . As i n a ll
dysfu nc t ions L hese e xe rc i s e s s ho u l d rep ro d u c e the p a t i e n t 'S pa i n ,
but
n o t i n a la s tin g wa y lsome t r i c c o n trac ti ons c a n be d o n e b y squeezing a p i ll ow or ball b e t ween
d o ne in s ta n d i n g
the kne es . A d d u c tor streLches can ei t h e r be
in a l u n ge p o s i t io n , s i t t i ng
wi th t h e soles 0[' the fe et
toge t h e r and pu s h i ng the k nees d o w n wi th the elbows , o r
FA B E R p o s i ti o n
u s i ng the
The p rogra m m e s ho u l d pro gress i n t o dyn a m ic
e x e r cis e s , fi rs t w i t ho u t res i s t a nce then wi th resis t a n c e o n c e the i s o m e t r i c exerc i ses are ea s i l y t o l er a te d ( s e e L i n ds a y e t al. 1 9 9 4 )
Pe r forming add u c l a r s t r e t c h es be fore s p o rting activi ties is an e s s e n t i a l
p a r t 0 1 p reventa tive tra i n ing t h a t t h e i n d i v i d u a l s hou l d maintain in the fu t u re (Rens tro m 1 9 9 2 )
Achilles ' tendon injuries Ach i l l e s' ten don pro b l e m s a re common w i th re c re a t i on al a th l e tes (A l l en mark 1 9 9 2 )
They represent a range o f t e ars , in flamma tion
and d e ge n e ra t i o n o f t he t e n d o n i t se l f and/o r the su r r o u n d i n g
p a ra t e n o n , wh ich a ll bene fi t from a si mila r ma na ge me n t a pproa c h (A l l enma rk 1 9 9 2 ; G a l low a y
et
a 1 . 1 9 9 2 ) A l though acu te tea rs may
go t h ro u gh the n orma l sta ges of infl a mm a t ion , rep air and re m o d e ll i n g in a stra i gh t fo rward m a nn e r , as w i t h all ten d o n i nj u r i e s h ea l ing may
be re tard e d and the p ro b lem b e c o m e c h ro n i c The onset also may be
i n s id i o us s u ggesting a d e gene rative or overuse c o m ponent to the a e t i o l o g y (All e n m a r k 1 9 9 2 ; Ga llow a y et a1. 1 9 9 2 ) The condi tion t hus exem p l i fi e s many of t h e typical p ro b lem s tha t c o m pl i c a t e the
h e a l i ng res p on se s of tendon i nj urie s
Typ i ca l l y t h e p a tient is a b le to localise the s i t e o f the probl e m ;
it is
tender to the t o u c h and some times swollen. Stretching the c a l f w i t h d o rsi fl e x i o n is pa i n fu l a n d l imite d . This c an b e d o n e a ga ins t a wall
with fee t aligned at an equal d is ta n ce from it, which a ll o ws c ompa ri s on
wi th the non - inj u re d leg. The stretch should be done both with knees exte n d e d and fl e xe d ; t h is pu ts more tensio n o n the ga st rocn e m i u s
a n d s o l e u s com p o n e n ts o f t h e muscle . Resis ted movements will be
TEN
1 241
242 1 C IiA P T E r1. T E N
T i l l H U M A N E XT R E M I T I E S :
M E e H AN I C A l
D I A G N O S I S & T f l E RA I ' Y
pain fu l ; ge tting the pa tient to p e r form h e e l rai ses fi rs t o n b o t h toes , t hen on the a ffec ted leg only, if pain p e rm i t s , best tests t h i s .
The p a t h o l o gy varies d e p e n d ing u p o n t h e stage 0 1 the d i s o rd e r (Ga l loway e t a l . 1 9 9 2 ) E a rly o n , in namma tion 01 t h e p a rate non may be the key linding acco m panied by gran u l a ti o n tiss u e , o e dema a n d t h ickening. If t h i s is allowed to hea l the p ro b l e m s h o u l d b e sel f limiting, bu t w o rking t h rough the p a i n m a y c a use scarri n g an d s tru c t ural d isru p tion o f the te ndon . Degene rative c hanges can occu r
Pho t os 9 7, 98, 99
Calf stretch. The jJalieni stands at ann :" length (rum tbe wall, feel /Joill/ illg fo rtl '{lrd a n d (lal a l l Ihe floor
(9 7). Keeping the heels flat and tbe k n ees ill extension tlwy lean fo rward, sire/ch ing
(')8). Fro lll knees (Ire lIllou 'ed to iJenci (»' jJusbillg fbe (} O/IO I I I O l l t, slil/ keejiil 1,� IiJe f)ee/spal o n the flow; tbe sole", is stH:tched (99). Each stretch s!Jo u ld iJe repea ted abo u t lell times Oil cacb occasio J / . I his sl reteb "I/OlI 'S compariso/1 (wl l l 'een I/:Ie the gas / ro u / e l l / e l l s
tbis jJosilio n , i/ the
inj u red {l n d Hon-il/ju red leg.
97
98
99
C O M ,'vI O N D I S O R D E RS
in
C H A PT E R T E N
the tendon - m i c ro - tea rs , in flammation and fibros is may p ro mote
weak and poorly orga n ised scar tissu e . These changes can acce l e ra te fu rthe r te n d o n degradati o n . There is an area of low vascu lari ty two [0
six cent i m e t res proximal to the calcaneus , and this may become
v u l nerable
[0
A co m p l e te
ischaemic i nsu l t , which fu rther weakens t he structure .
rup ture of the tendon represents the e n d po int of t h e
d e ge n e r a t i v e process ( G a l loway e t al. 1 9 9 2 ; Al lenmark 1 9 92) Such
ru ptures a re al ways p receded by degenerative and structural changes , often Lhose assoCIated with h y p o x i a . Prior to spontaneous rup ture many p a t i e n ts a re completely asymptoma t i c and could recal l no warning signal ( Ka n n u s and Jozsa 1 99 1 ) Th is finding makes i t clear that su bsLan t ia l d e gen e rative changes can occur in the tendon which leave
iL
s e r i o u s l y weakened w i thou t any p revious symptomatic
i m p l i c a Li o n s . Wh i le patients who i ncur other tendon ruptures a re
ge ne ral l y o v e r 6 0 , the average age of the patients wi th Achilles' tendon ruptu res is 3 6 ( Kannus and Jozsa 1 9 9 1 ) There i s still debate over whe the r the best t reatment for Ach illes' tendon rupture s is s u rg ic al re pa i r or immobi lisatJ o n in a plaster cast (Grisogono 1989) Management a n d self-treatment exerc ises
AC Ll te i n j u ries w i n need the Rest , Ice , C om pression and Elevation ( R I C E ) protocol i n the first fe w days and gentle range o f movement ,
non-weight-beari ng exe rcises fro m the second or third day. These s h o u l d be p r o g r e s s e d on t o w e i g h t - b e a r i n g s t re t c h e s a n d stren gthening exerc ise s . The time frame for individual progressio n depends u po n t h.e severity o f the damage , and i s best gauged through assessm e n t of sy m p to ma tic re sponses to load ing s trategies . See Li ndsay
et
a t . ( 1 994) fo r more detail on acu te inj u ries . N SA1 Ds ,
a lthough wid ely p rescnbed fo r musculoskeletal overuse inj u ries , have not been conclUSive l y shown to re d u ce recovery time (Gall oway et al 1 9 9 2 ; A l lenmark 1 9 9 2) O n e o f t h e most im portant factors to p romote he a l i n g in tend o ns is
early functional aCllvity ; this accele rates paral lel alignment of collage n f i b r lls a nd p romotes tensile st rength (Alle nmark 1 9 9 2 ) Thus th e
two key aspects o f management are l he s t retching and stre ngthe n ing com ponents. Stre tch ing the tend o n with wall leans , knee l1exion and extensi o n should conti n u e until the tendon fe e ls the same as the non - i n j ured leg. It is importan t to make c lear [ 0 the patient that
continu i n g s L re tc h i ng a ft e r the iI1J ury is a vital part of preve n t i o n o f fu rthe r p ro b l ems (Gal l owa y
et
al . 1 9 9 2 )
1 243
1
244 C H A rT E R T E N
T H E H U M A N E XT R E M I T I E S : M E C H A N I CA L D I AG N O S I S & T H E I\j\ I' Y
PiJotos 1 00,
1 1) /
lendo n and
calf; e a rl )
f
Iso lonic exercise or A chilles ' '
lueigb'
The palienl sla rts with lve ig h t e l 'en�)1 sp read
oem'ing
�
on
bolh feel, hands gel l l ) ' resl illg
wulls li)r sufi/Jorl Ibe)!/s/!! , 'es o i l i o their toes ( f O I ). To be repealed lip 10 Ie II l i m es on Ihe
( 1 00). 11>1')' raise
100
Pbutos
fOf
1 02, 1 03
Single-leg eC('e n lric loadill!}, of
the A ch illes ' leI/doH dm'! ng
rehabiliiati(J / 1 of a cbm l l ic
p ro b le m . Sla rt ,o iliJ Ibe
affected leg j)/tl l l larjlexed and u n loaded, bf're Ihe right leg. The patie l l i lhell Ir(/J/.yers Ibe , , 'eigbl Oll to Ihe alle c led leg and 1()l{Je r�" Ihe beet O f Jcr the oack of Ih e slair o r c/Jail:
prooiriing ecce n l ric loading.
'fiJis
is
repea ted tell
filll f's. Ti)
apply ()n lv eccell iric loading
the olher le8 is used 10 rel u rn 10 the s l u rl P,,,-il ion .
lhe
procedure is besl appli a sillircase,
0111
ed Oil
so/nc /hl l ie l 1 ls
prefer Ibe Sla/J ilil), of {/
b i!;h nJe !Jasic jJosili()11 ca n also
backed din ing cbai l:
same
be Itsed for less loodillg by pelfonn ing the exercise o n both feel, or t o
co n ce n tr i
1 02
loading 1)1 '
1 03
leg
do
bollJ
c (/Ill/ ecce n tric
using Ibe a/fecled
10 relllrn Iu I b
e :;101'1
positio ll.
E a rly s tre ngthe n i n g n o n - weight - b e a ring e x e r c i se s in
mj ury
c a n b e done u s i n g flexi -bands .
These
a
sub-acute
sho u l d p rogrl' ss t o l o e
u p s w h e n t o l e ra b l e - t h a t i s , n o lastin g p a i n is provo ked these a re
done
on b o th fe e t , with s u pport fro m
an
Initia l ly
a r t i c l e o f fu r n i t u re
i f n e e d e d , and then progressed o n to the inj ured le g o n l y This progresse d b y performing the s a m e e x e rc i s e with
si de
the h e e l s
can
be
ove r l h e
o f a s t a i r. In this wa y concen t ric a n d e c c e n t r ic e x e rc ises c a n b e
d o n e thro u g h o u t t h e enti re range . T h i s c an be clone i n i t i a l l y
on
b o th
C H A PT E R T E N
C O ,V\ Iv\ O N D I S O R D E RS
legs , an d then only one as to l e ra ted . It is i m p ortan t t h a t e c ce n t ri c exerc ises a re part o f th e re habilitation process . These e x e rc is e s
are
the o p t i m a l wa y to get s t re ng th g a i ns (Fy fe and S tanish 1 9 9 2 ) , a n d ec c e n t r i c con t ract ions are th ought to have a prime r o l e in c a us i n g t e n d o n i nj u r i e s it is i m p o rtant to s pe c i fi c a lly str e n g t he n the muscle as
in that mode ( G a l l o w a y e t al. 1 9 9 2 )
M a n y p a ti e m s a r e s e e n w i t h c h ro ni c Ach i lles' tendon p rob l ems These need t o be a d d re s se d in t he usual way with contractile dysfu n c tions . The a b i l i t y o f t h e t issue t o stretch and contract needs to be restore d . This c a n be cl one u s i n g t h e re gime o f s t re t c h i n g and s t re n g th e n in g a s o u t l in e d above . I t h a s a lso
been sh o w n
that a p ro gr a m m e o f e cc e n t r i c training is
h i gh l y e lTi c a c i o u s in c h r o ni c Achilles' t e n d onosis which has not r e s p o n d e d to o t he r conse rva t ive treatments and w h e n s u rge ry was b e i n g c o n s i d e re d ( A l fr e d s o n e t al. 1 9 8 9 ) . These p a t i e n t s , a l l
recreationa l
a t h l e tes , h a d sym p toms for a n average o f
a
year and a
h a l f a n d h a d n o t bene fi ted fro m res t , N SAIDs , o r th o t i c d evices , p h YSi o t he rapy o r o r d i na r y traini ng progra mmes . E x e rcises were pe r formed tw i ce d a i l y, every day
fo r
time ru n n i n g w a s pe r m it te d o n l y if discomfort. n t e p r ogra m m e c o n s i s t e d
twelve we eks , d urin g which it p ro v o k e d m i n i m a l o r
no
so l e l y of eccen tric e x e rc i s es
the no n - i nj u red leg was used to return to t h e start pos i tion . They were d o ne w i t h heels over the
e d ge
of a s ta i r p r og re s s i n g from both
fe e t , to o n e fo o t , to i n creased l o a d s (by a d d i n g wei gh t in a b a c kpack) as the p r e v i o u s e x e rc i se be c a m e p a i n fr e e -
.
A fter the twe lve -week
t ra i n i n g progra mme all fifteen p a ti e n t s we re back a t
their p re i nj u ry -
le vel o f ru n n i n g activi ty, t h e calf muscle s t re n gt h had re turne d t o bemg s i m i l a r to the n o n inj u re d leg, a n d pain was now min i ma l . A -
c o m p a ri s o n gro u p w h o also failed to improve with conventional
trea tment and c a m e to s u rge ry took twice as long to re turn to full ru nning activi ty ( A l fre dson e t a l . 1 9 89) .
Pate l lofemoral joint pain Knee pain is a com m o n c o m pla i n t am ong the g e n e r al p o pu l a t i o n
with p re v a l e n c e ac ross a l l age groups o f be tween 1 0 and
Te n n a n t 1 9 9 2 ;
-
,
15% (B a dle y
Cunni ngham a n d Kelsey 1 9 84 ; Hadler 1 9 9 2 b )
Osteoarthritis (OA) only a c c o un t s fo r a p ro porti o n o f these knee pains; the res t are u n d i a gn o s e d or n o n s p e c i fi c Wi thin t h e older p o p u la t io n -
.
1 245
246 1 C H A PT E R T EN
T H E H U M A N E X T R E M I T I ES: M E C H A N I CA L D I AG N O S I S
& T H E RA PY
(over 5 5 ) isolated symp tomatic p a tell o femoral J o i n t OA has been estimated to a ffect 8 % o f women and 2% o f men (McA l indon 1 9 9 2 ) . The role of the p a tell ofemoral J oi n t
in
et
al.
you nger groups is
u n c l e a r with the non - s p e c i fic c l a ss i fi c a t i o n of ' k nee pain' n o t d i fferentiated into aeti ological grou ps . Abno rmali ties of the J o int have a c c o u n t e d fo r a b o u t 1 0 % o f k n e e assess m e n t s by a rth rosco p y (Lindberg
et
p ro b l e m s (N
a l . 1 9 86) In a sports inj u ry cl i nic 2 5 % o f a l l knee =
5 4 9 ) w e re re l a te d t o the p a t e l l o fe m o r a l j O i n t
(Devereaux and Lachm a nn 1 9 8 4 ) This l i m i t e d e p i d e m i ological i n fo rmation s u ggests that the j oint is freq uently i n v olved i n knee p roble m s , but that a more precise estimate of its ro l e in ' knee pain' as a whole awai ts fu rther elucidation . The issue is fu rthe r c o n fused by the u ncertainty surro u nding validity and re liab i l i t y in d e te r m i n i ng a speci fic diagnosis . P a tel1o femoral j o int problems or a n t e r i o r k nee pain is genera l l y d i s tingu ished from c h on d ro m a l a cia p a t e l lae a nd o s t e o a r t h ritis . S ymp toms of anterior knee p ain can a rise witho u t t he patho logical c h a nges t o t h e c a r t i l a ge o r bone w hi c h a re c h a ra c te r i s t i c o f c h o n d ro m a l a c i a p a t e l l a e o r o s t e o a rth r i t is ( l n s a l l 1 9 7 9 , 1 9 8 2 ; Fulkerson and Shea 1 99 0 ) These changes , t h o u gh , a re fre qu e n t l y incidental findings
in
the normal popu l a t i o n (Stougard 1 9 75 ; I nsall
1 9 8 2 ) Thus pain can ex ist in the absence of pathoanato m i ca l cha nges , but equally morphological c hanges do not al ways p re d ic t s y m p to ms I n those with anterior knee pain i t is likely that t h e re is a continu u m
from patellofemo ral J oint p a i n wi th o u t p a thoana t o m ical c h a nges to chondromalacia wi th actual softe n i n g , fiss u ri n g a nd fasciculation of the carti lage . I t i s widely stated tha t t h e symptoms o f pate l lofe m o ra l J o i n t pain
a rise due to mal a l i gnment of the pate l l a in the fe mora l gro ove C l nsa ll et
al. 1 9 7 6 ; Insa1l 1 9 7 9 , 1 9 8 2 ; McConne l l 1 9 8 6 ; F u l ke rson and S he a
1 9 90) T h e p a tel la is a sesamoid b o n e w i th i n t h e quadr iceps and i ts e qu i l i brium within th e groove is al ways o pen to the in fl uence o f static and dynamiC factors a t o r abo u t the knee (Schu tzer e t al. 1 98 6 ; Kettelka mp 1 9 8 1 ) the configu ra t i o n o f the pate lla may b e a b n o rmal •
t here may be d e ficiencies in the su ppo rting s o ft t issues a b o u t t h e patella there may be abn ormalities
in
pan of the lower l i rn b
COMMON
C H A PT E R
D I S O R D t RS
T h ree a bno rma l c o n fi gu ra ti o n s of the p a t e l l a have been i de n t i fi ed .
Sy m p to m a ti c p a t e l l a e h a v e bee n se en to be l a t e r a l l y shifted , l a t e r a l l y ti l l e d , or b o t h late rally s h i fted and tilted
( Sc h u t z e r
et
al. 1 986;
F u lkerson and Shea 1 9 90) The h e i g h t o f the p a t e lla from t h e tib i a l
t u b e rc l e m a y a ls o be e x c e s si ve , a fin d i n g k n o wn a s p a t e l l a a l t a , p re d i sp o s i ng to excessive l a t e r a l s hi ft (Insall 1 9 8 2 )
I t h a s b ee n
suggested t hat ex cess ively tigh t lateral retinaculum may tilt the p a te l l a ,
a n d that i n su ffi c i e n c y o f vastus medial is o b l i quu s m ay c o n t r i b u t e to
l a t e r a l shih ( F u l k e r s o n 1 98 3 ; Fu l k e rs on and Shea 1 9 9 0 ; Mc Connell
1 9 86; l nsa l l 1 98 2)
Fa c t o rs e x te rnal
to the knee have also been bl a med
fo r some o f the symp tomatolo g y C ommo n l y stated abnormalities of the l ower l i m b a re i n c rea s e d Q an g l e , excessive p ro na t i o n o f the
su b t a l a r
j oint , and
t i g h t ne ss of re ct us femoris , the illio tibial tra c t ,
h a m s t r i n g s o r g a s t ro c n e m iu s ( Ke t t e l k a m p 1 9 8 1 ; I n s a l l 1 9 7 9 ;
M c Connell 1 9 8 6 ; H i l y ard 1 9 90) Co mbina tions o f a b n o rmalities are not u nusual ( K e t t e l k a mp 1 9 8 1)
N o t al l the se tactors have a p ro ven role in the pa t h o ge n es i s o f ant e r i o r knee p a i n . For ins t a nc e , t h e ro l e o f the i lliotibial t r a c t has been
q u e s t i o ne d ( Rouse 1 9 9 6 ) The a e ti o l o g ica l si g n i fi ca n c e of s o m e of t h e othe r fac tors i s by no m e a ns establishe d . T h e v a r i e ty o f fac tors that di ffere nt a u th o rs s pe cu l a t e a re s ig n i fica n t in the a e ti o logy o f
p a t e l l o fe m oraL prob le m s undermines their clinical use fulness The
p o o r - to - fa i r re l i a b i l i t y o f four c om m o n l y u s e d tests t o j u dge for p a t e l l o fem o r a l a l i g n m e n t fu rthe r c omp ro mis es clear re c o gn i t i o n of a
d i s t i n c t diso rder ( F i tzge ra l d and M c Clure 1 9 9 5) . H o wever, the key fa c t o r in s ym p t o m p ro d u c t ion w o u l d a p pe ar to rela t e to a b n o r m a l mech a n i c a l force s at o r abou t the knee tha t alte r
the p os t u re of t h e p a te lla statica lly or d y n a m i c a l l y and c o n se q u e n tly cause e x cessive l o a d s th rough the j oi n t . A thorough e x ami n a t i o n must inc l u de all the m e c ha n i c a l a b n o rm a l i t i e s that may h a v e a role in
sym p tom p rod u c t io n . Not all these fa ct o rs may be o p e n to change , a n d o f t hose that a re a p ro l o n ged com mitme n t fro m t h e patient i s
require d t o bring ab ou t a chan ge . Perceived a bn o r ma l i t i e s may also b e fo u n d i n t ho s e w i t h o u t s y m p to m s . F u r the rm o re , a b n o r m a l me chanical fo rces a re e xa ce rb a ted d u r in g l o a d e d fl e x i o n activi t i e s , w h i c h magnify the p a tel l o fe m o r a l joint re a c t io n forc e . F o r i n s tan c e , knee-b e n d i n g o r c l i m b i n g s t airs c au ses fo rc e t h ro ug h the J oint at 2-
3 times body we ight , w hile wal king on a l e v e l su rface the fo rce i s
h a l f body w e i g h t ( N ord in a n d Fran kel 1 989b)
TEN
1 247
248 1 C H A PT E R T E N
TH E
H U M A N E XT R E M I T I E S :
M E C H A N I C A L D I A G N O S I S & T H E RA P Y
Where is the pain c o m i n g fro mt T he pa te l l a cartilage is the thi c k e s t in th e
body ( E v a ns 1 9 86) ; c a rt i l age is a n eu r a l and the re fo re i nca p able
of being the source of symp toms It is t h o u g h t that p a i n might b e caused by increased stresses on the su bc h o n d r a l bone (Good fe l l o w
e t al. 1 9 7 6 b ; Gruber 1 9 7 9 ) . M o re s p e c i fi c a l l y, i t h a s a l s o b e e n p ro p ose d that p a t e lla r pai n re su l t s fro m h i gh i n tra - oss e o u s l evels o f
p re ss u re w h i c h ca us e pa i n fu l abnorma l i ties i n t h e v asc u l a r s y s t e m i n
t he b o n e ( A rn o l d i 1 99 1) These i ntra-osseo us p ressu res a re ma g n i fied d u ring flexion .
A l t h o u g h p a t ients w i th severe stages o f cho n d ro malacia p a te l la may
show sign s of infl amma tion involving t he c art i l a ge , the synovium o r
the p lica (A rnoldi 1 9 9 1 ) , genera l l y syn o vi t i s i s a rare and inconsistent fi n di n g even i n th os e with sym p t o ms seve re e n o u gh to seek s u rgery
( [ ns a l l et a l. 1 9 7 6 ; Gruber 1 9 79) . There fo re i n m a n y pa ti e n ts pain is not the p ro d u c t of inflamma tory chemicals but is due to abno rmal postu ral mechanics . A c o mb i n a t i o n o f tig h t s o ft tissues a n cl/or a l tered a l ignm e n t o f the p a te lla g e n e r a t e s p o i n t s of excessi ve p ressu re .
Ultimately th i s may c a use the gross changes t o the
c a r t i lag e te rmed
cho n d romal acia . 'vVh e n fo u n d , these are p rinci pally located ro u ghl y in the c e ntr e o f the p a tel l a e xten d i ng m e d i a ll y and l a te ra l l y ( l n s al l e L
a l . 1 9 76 ) . C o n tact a reas and p ressu res b etween the p a t e l l a a n d t h e fe m u r a l ter w i t h t h e flexion angle o f t h e j oi n t . As t he J o i n t m o v e s fro m extens i o n
t o fle x i o n , the c o n t a c t area moves from t h e i n ferior to s u p e rior aspect o f the p a tella (Good fellow et a l. 1 9 7 6 a ; H u b e rti a n d Hayes
1 984) .
The area w h e re d a m a ge tends to o c c u r is i n c o n t a c t at a b o u t 60 to 9 0
d e gree s . Contact p ressures are also high es t between 60 a n ci 9 0 d e g re e s
(Huberti and H ay e s 1 984) . Thus the abnormal bio mechanics are e x a ce rb a ted d u ring flex i o n l o a di n g ac tivi t ies to gene rate a fOC Ll S o f
excessive p re s s u re o n the p a t e ll a , which ulti mately causes symp toms The problem thus has a dyna miC
c o m p o ne n t . Va s t u s m e d i a li s
o b l t q u u s is t h e o n ly dyna m i c s tabiliser o f t h e p a t e l l a , a n d t h u s i n s u ffi c i e n cy o f this muscle w i l l i nc r e a se l a t e ral s h i ft ( Mc C o n nell
1 986) Clinical presenta tion
The typical p a te l l o femoral j o i nt p a t i en t is a y o u ng p e r s o n , fro m teenager to twentie s , without a h i s t o ry o f i nj u ry, and mo re li k e l y to
be fem a le . S ymp t o m s may have been p re s e n t [o r many mo n t h s o r
C O M M O I"!
D I S O IZ O E RS
C H A rT E R T E N
even yea rs , and altho u g h u s u a l l y fe l t around the p a t e l lar, they a re sometimes re ferred to the posteri o r o f rhe knee also . A l a rge m i nority o f p a t i e n ts have b i l a te ral symp toms . Activi ties of f1exion are t y p i c a l ly painfu l . This may present as i m m ediate pain on l o a d e d activi ties , s u c h as s q u a t ting o r ascend i n g/d e sce n ding stairs , or as p a i n b rough t on by s u s t a i n e d l o a d i ng, s u c h as mainta ining knee tlexion at 90 degrees w h i le 111 the ci ne ma . Pa tie n ts may describe the grad u al onset o f pain a ft e r s u s ta i ned activi t y. Only s o me times is trauma involved in o nse t . Pain may b e fai rly constan t or clea rly rela ted to a c tivi ties . On exa m i na Lion fi n d ings a re o ften minima l . Normally active range
of u n l o a d e d m o v e me n t is fu ll , a l t h o u g h there is o ft e n p a i n on squatting When i t comes to d e te rm i ning the presence o f sh i ft , t i l t a n d ro t a t o ry malalignme n t , re lia b i l i ty be tween clinicians is only poor to fa i r (Kappa
=
0 . 1 - 0 3 6 ) ( F i tzge rald and McClu re 1 9 9 5 ) O ther
suggested fi n d i ngs i n c l u d e increased p rona tio n , increased
Q
angle ,
illioti b i a l tract tigh .tness , squinting p a t e l lae , patella al ta , hams t r i ng tig htness , or pate l 1 a s h i ft or t i l t . Resiste d ex tension a t s o m e point in the range is n o r m a ll y b u t n o t a l ways p a i n fu l ; compression o f the p a te l l a o n t o t h e fe mu r may p rovoke pain at c e rta i n angles ; and there may be tende rness on palpation o f the u n d e rside of the patella . O ften t here is a p a u c i ty o f abno rmal fi n d ings o n physical examinati o n , wi th t he i n fo rmation gained from the history-taking most clearly indicating a n te r i o r knee pain (McCo n n e l l 1 9 8 6 ; I nsall et al . 1 9 7 6 ; Insall 1 9 7 9 ; Ge rra rd 1 98 9 ; Bentley and Dowd 1 9 84) Natu ra l h i story
The nat u ra l h isto ry of t h i s cond i t io n has n o t been much studie d , b u t e vi.d ence sugges t s a p rolonged history is n o t uncommon in many patients Ka rlson ( 1 9 3 9 ) stu d i e d a group of p a t i ents fo r up t o twenty years who had rece ived o p erative and non-ope rative treatme n t , wi th a diagnosis o f c ho n d ro ma lacia pacella e . Over a th i rd o f the surgical group and 8 6 % o f the c o nserva tively t reate d group continued to have sympt oms and fu nctional l oss . Only a few deteriorate d , b u t 2 2 % o f t h e no n - s u rgical gro u p h a d severe symp toms . Hvi d e t al. ( 1 9 8 1 ) also s t u d i e d those w i th a d iagnosis o f chond romalacia p a tellae of varyi ng gra d e s fo r t h ree to e i gh t y e a rs . The m aj o r i t y were worsened or unchange d , with a poor p ro gnosis being associ a t e d with cl i nical or
radiogra p h ic mar kers of abnormal pate l l o fe m o ra l b i omechan ics . Robinson and Darra c o t t ( 1 9 70) fo u n d that 7 1 % o f their group had modera te to severe disa bil ity from knee pain two to six ye a rs aft e r
1 249
25 0
I C rl A [) T E R T E N
TH E
H U MAN
E XT R E MH I E S: M EC H A N I CAL D I AG N O S I S & T H E RA I'Y
the cond i t i o n had starte d . Devere u x a nd L ac h m a n n ( 1 9 84) fo l l owed
up a grou p of athletes w i t h p a t e l l ofe m o ra l pain fo r a b o u t a y e a r a fte r c onserva tive t h e rapy and found tha t o n l y 2 9 % we re e n t i rel y free o f sym p toms a t th a t time . In summa ry, fro m these long-te rm studies only about a qu a rt er of patients become
c o m p le t
e ly pain- fre e i n this
condition . The natural h is t ory of a speCI fi c s u b - gro u p
,
a d o l es c e n t
g i r l s has bee n ,
foll owed over t w o t o elgh t ye a rs ( Sand ow and Good fe l low 1 9 8 5 ) . The maj ori ty still had symp toms , b u t in ov e r 8 0 % th is was weekly or less fre q u en t ; in the m aj o ri ty res tric t i o n of s p o rLi ng a c t ivi ty was occasional o r not at all . N early ha l f re p o rt e d themse lves b e t t e r o v e r t he follo w - u p period , about 40% the sa m e , a n d o n ly 1 3 % re p o r t ed a wo rsening of p a in seve rity. F rom t h e s e re ports it wou l d seem that p a t i e n t s c o u l d have very pe rs is t e n t sym p t oms , but th a t a d o lescents in p a rticu l a r
c an
the m aj o rit y
d o no t p rogress . Female
have a reasonab ly goo d prognosis i n
the l o ng term with li ttle fu n c ti o n a l restriction and o n l y i n f req uen t ,
pain . H o wever, it wou l d a p p e a r t h a t i n o t h e r g roups t l1e p rognOSis i s n o t s o goo d . M o s t w i l l h a v e pe rsis t e n t sympto m s , and unless th e abnormal biomechanics o f t h e j o int c a n be a l te red these a re u n l i kely
t o c h a nge . I n d ee d , many p a ti e n ts are d es c ri b e d who have had symp toms that h a v e persisted fo r y e a rs ( M cConnell 1 9 8 6 ; Ge rrard
1 9 8 9 ; S a nd ow a n d G o o d fellow 1 9 8 5 )
Management Conserva tive manageme n t has traditi onal ly been based o n res t d u ring a c u te phases , a v oidance of flexed , loaded knee positio ns , straight l e g r a i s i n g q u a d r i c e p s s t re n g t h e ni ng e x e rc i s e s , N S A I D s , a n cl -
occasional use of bracing or immob i l isation (Fishe r 1 9 8 6 ; K e t te l k a m p
1 9 8 1 ; I nsa1l 1 9 82 ; F u l kerson and Sh e a 1 9 9 0) . The va lue o f N SA l Ds is unproven - one small trial comparing asp i ri n t o p l acebo found
no
sig n i ficant d i fferences between the t wo groups (Bent ley e t a l . 1 9 8 1 ) The e ffec tiveness o f exerc ises i s s a i d to b e unqu e s t io nab le bu t the ,
mechanism fo r their e ffec t is u n c l e a r. Exe rcises sho u l d not be pain ful and must e m p hasise vas t u s me dialis o b l i q u u s Onsall 1 9 8 2 ) M o re recen t l y s t re t c h ing o f s o ft tiss u e s arou n d t h e knee has a l so been
th ou gh t t o be important (Fu l kerson and Shea 1 9 90) C o n t roll e d tria ls of these in terventions have not been d one , so the i r true worth is i m p ossib l e t o s u bstan tia te .
C O M M O N D I S O R D E RS
C H A PT E R T E N
M c C o n n e l l ( 1 9 86) p r o p o s e d a s i mH a r b u t more focused management ,
a p p r o a c h This i n v o l ve d s t r e t c hin g a ny tight stru c tu re s , such as t h e
i l l i o t i b i a l t r a c t , l a t e r a l p a t e l l a re tin a c u l u m o r t h e h a m s t r i n g s ; c o rre c t i o n o f any mala l i gnment o f the p a t e l l a (shift , tilt or ro tatory c o m p o n e n t ) using tape ; a n d then p rogressive t rain ing o f the vastus
m e d i a l i s o b l i q u u s t o maintain i mproved c o n tro l over the p a t e l l a
.
E x e rC Ises a re d o ne i n a l o a d e d p o si t io n m u s t only genera t e minimal ,
d i s c o m fo r t
,
if a n y, and m us t include eccen tric mu s cl e work. Two
u n co n t rol l e d stu d i es o f a l a rg e series o f p a tie nts re p o r t go o d resu l ts in o v e r 8 0 l)6 o f t he p a ti e n t s ( M c C o n ne ll 1 9 8 6 ; Gerra rd 1 9 8 9 ) . I m p ro ve m e n t pe r s i s te d at o n e yea r as l o n g as pa tients maintained
the e x e rcises .
Re s p o n se was p a rticu l a rl y goo d and rapid in
those
whose sym p t o m s c o u l d be pro v o k e d b y s ta i rs , s q u a t ting o r resisted q ua d rice ps , wh i c h was i m p roved a fte r taping. By the end o f t reatment
s y m p t o m a t i c responses t o a range o f t es t s became p a in - free . Mecha n ica l d i a g n o s i s a n d therapy
P a t i e n t s wi t h p a te l l o femoral pain pro b l e m s d o n o t fi t ne a t l y into one o f t he three mechanical syndromes ; neither d o these p a tients ge nerally have i n fl a m m a t o ry p a i n There is s o m e c o n fu s i o n over a e ti o l o gi c a l
fac t ors a n d p ro b l e m s w i t h tests u s e d to m a k e t h i s d i agn o s i s . I t i s u nclear i f n o n s pe c i fic k n e e p a i n is u nW i t t i n g l y b e i ng i n c l u d e d i n -
th i s gro u p , a s t h e c r i te r ia for inclusion a re so b ro a d an d o f t e n there is so l i t t l e t o see . As i n m o s t c on d i ti o ns t h e hi s t o r y fre q uen tl y plays the most i m p o n a n L role in i m p l ica ting the pa tello femoral j oi n t , w ith
exacerba t i o n o f sym p to m s on ac tivi ties o f flexion being t he m o s t c o nsi s t e n t fe a tu re . La c k o f clear p hy s i c a l fi n d i n g s o b sc u re s the
d i re c t i o n m a n a g e m e n t shou l d take . There is no certainty concernmg vario us issues t h a t rel a te to Lhis c o n d i ti o n . H o w e v e r , fre q u e n t l y t h e s e p a t i e n t s have a p e r s i s t e n t p o s t u r a l
a b normal i ty w h ic h c o m es to ge n e ra t e an a re a o f s e ns iti sed tissue on the u n d e r su rface o f t h e p a t e l l a . T h e a b n o r m a l ity may be t ight l a teral s t r u c t u r es and s h i ft o r t i l t of the p a te l l a , o r some combin a ti on of the fa c t o rs o u t l ined above . O ften this ,viii only p rod u c e sym p to ms d u ri n g
o r e v e n a l t e r a c t i v i t y I n o t h e r w o rd s , m i n o r b i o m e c h a n i c a l
abnorma l i ties cause symptoms in the dynamic phase o f knee fu nction - this is a d y n a m i c p o s t u r a l syn d rome . U l t i m a t e l y this may progress to c o n st a n t pain , when the p r o gnos i s is p o o r. The abnormal p os t u ra l
mecha nics t h a t c o m e to ge nerate sy m p t o ms needs a lasting c h a n g e to i m p rove the c o n d i t i o n . This can only happen o v e r t ime . Tight
1 251
252 1 C H A PT E R T E N
T H E H U MA N E XT R E M I T I E S : M E C H A N I C A L D I A G N O S I S & TH E RA ! ' Y
s tru c t u res will have to be stretch e d and v a s t u s m e d ia l is ob l i q u Ll s fu nction will have to be im p roved . The se ns i t ised area o f t h e p a t e l l a m a y need t i me t o re turn t o norm a l . Th ro u ghou t this process p a tient com m i t m e n t i s essent i a l . T h is can only b e based on excel l e n t information provis i o n by the cl inician
a n d avo i d a n c e of a n y p assive mod a l i ties , the use of w h ich d e nies the p ivotal role that the p a t i e n t p lays i n reha b i litation . Se lf-treat m e n t exercises
M a n a g e m e n t o f a n t e r i o r k n e e p a i n e s s e n t i a l l y i n v o l ve s t h e n o r m a l i s a t i o n o f a n y tigh t local a n d l o w e r limb s t ru c t u res , a n d sec o n d a r i l y op timisa tio n o f v a s t u s m e d ia lis functi o n . Stretches may
need to be applied to lower limb muscle gro u ps , the i ll i otibial tract or the l a teral retin a c u l u m of the patella , as i s app l i cable fol l O Wing t h e physical e x a mination. Tra inin g of the quadriceps m u s t be d o n e i n weigh t -bearing a n d dynam ical ly, wi t h o u t aggravation o f sym p toms . Mini-squ a ts and lunges o n t o the a ffected leg a c h ieve t h i s ; i [ t o l e rated , s q u a t ting can be p e r fo rmed w i th min i m a l s u p p o rt fro m the other l e g S t a r t exercises severa l times da ily. I f these a re being performed I,\ri tho u t problems , progression invo lves the use o f a st a i r - s t e p ping up a n d down can be p e r formed w i th the a ffected l e g doing t h e m a i n w o r k e a c h t i me ; s t e p p i n g d o w n i s u s u a l l y m o re d i ffi c u l t Lasting pain o n any e x e rcise is a contra i n d i c a tion to that pa rtic u la r loading, as p a i n i n h ib i ts s t rengt h ga i n .
C O M M O N D I S O R D E RS
Fi g ure
C H A PT E R T E N
Assessment sheet
10.5
- a n t erior
knee
pain
TH E M c K E N Z I E I N STITUTE P E R I P H E RA L A S S E SS M E N T
.I . .
Date
. ..
. . 1.
Name Address .
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Date of b i rt h . Work
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SYMPTOMS
H I STORY
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Yes
t n t e r m i tt e n t
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.
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1 253
254 1 CHAPllR T E N
TH E
H U M A N E xT R E M I T I E S :
M ECHAN ICAL
D I AG N O S I S
& T H E RA P Y
. \'S� . D BJ::) .
PERIPH ERAL Observation
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Active movement Loss . .
Passive movement Loss . ( +I-over-p res s u re)
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Resisted
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tests R e s p o n s e
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E ffect o f repeated move m e n t s :
Effect of
static
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.
C H A PTE R
COM M O N D I SO R D E RS
Degenerative joint conditions I osteoarthritis The preva lence o f osteoart hritis increases l inearly with age from ab out 3 0 , b e fo re whi ch the d i sease hardly e x i s t s , with the ave rage age of onset b e i ng 5 5 . Be fo re 50 me n are a ffe c ted more th a n wome n , but a ft e r t h is age t h e p re v a l ence i n women is t w o or three times greater than m e n (Felson and Zhang 1 9 9 8 ; McCarthy e t al. 1 9 94) Symptoms
a re varied - pai n , achi n g , sw e l li n g , bony tend e rness and en largement ,
acti v i t y - re l a t e d p a i n , m o r n i n g a n d inactivity stiffnes s , c repi tus a n d pai n [u l l i m i t a t i o n o f movements (Oliveria e t al. 1 9 9 5 ; Huskisson and Hart 1 9 8 7 ; A l t m a n e t al. 1 9 8 6 ) The p resence of osteoarthritis (OA) is c o nfi r m e d by radiogra p h y ; h o wever, l a rge numb e rs o f ind i vi d u a l s w i t h t he rad i ograp h i c changes o f OA d o not have symptoms . V i s ib l e c ha n ges on x-ray increase with age a n d a re a l m o s t u n iversal a ft e r 5 5 , b u t i t i s estimated that only ab o u t 50% o f i n d i v i d u als wi t h these c h a n ges h a v e s y m p t o m s ( Hu skisson a n d Hart 1 9 8 7 )
For
i ns t a n c e , whereas 8 0 - 9 0 % of the popul a tion ove r 70 have rad i ogra p h ic changes i n t h e hands , o nly 9 % o f m a l e s and 2 6 % o f females have p a in (Petersson 1 9 96) Radiogra phic knee O A was found in 2 0 % o f a l a rge p o p u la tion su rvey, while only 5 % h a d these changes
and knee p a i n at the time of the survey (Claessens et al. 1 9 90) . Pai n ful knees accompanied by x - ra y changes occur in 6% of a d u l ts over 3 0 , wh i l e radio graphiC c hanges are fou nd in a b o u t 1 4 - 3 0 % o f those over 4 5 (FeLson and Zhang 1 9 9 8 ; Petersso n 1 9 9 6)
Symptoma tic
hip OA o c c u rs in 0 . 7 - 4 . 4 % of a d u l ts , while a b o u t 20 - 3 0 % o f w h i te E u r o p e a n s o v e r 5 5 d i s p l a y r a d i o gr a p h i c h i p O A - t h e p re v a l e n c e i s m u c h l ower (l - 3 % ) i n n o n - Caucasian p o p u l a t i ons (Felson 1 9 8 8 ; F e L s o n and Zhang 1 9 98) M o s t s t u d ie s s h o w t h a t the p ro p o rtion o f ra d i o l o gi c a l d isease tha t is sym p t o m a t i c is betwe e n 4 0 and 8 0 % . This d epends partly upon the seve r i t y of t he s igns and the site - severely d a m aged j o in t s a re more likely t o
be
p a i n fu l than m i l d change s , knees a n d hands a re mo re
l i kely to be p a i n ful than h i p s . Many peo ple with signs of OA do n o t h a v e p a i n o r have episo d ic o r intermittent pain ; many wi th o u t signs of OA can have p a i n fu l J o i n t s . The key message to p a t ients is t h a t radiographlc e v i d ence o f j oi n t changes d o e s not correlate c l osely wi th symptoms ( H o c h b e rg et al. 1 9 8 9 ; Spector a n d H a r t 1 9 9 2 ; Dieppe 1 9 8 9 ; Forman e t al. 1 9 8 3 ; Acheson 1 9 8 2 ) M y t h s ab o u n d c o ncerni n g O A , o n e o f w h i c h i s the i n h e re n t l y p rogressive nature o f t h e d isease
In fa c t not a l l p a tients p rogress
TEN
1 255
256 / C H A PTE R T E N
TH E
H U M A N E X T R E M I T I E S : M EC H A N I Ci\L D I A G N O S I S & TH U(A I'Y
r a d i o gr a p h i c a l ly o r s y m p t o m a t i c a l l y, a l t h o u g h m a n y d o . I n a s u b s t a n t i a l pro po r t i o n of those w i t h con fi rmed OA the sym p L ams either ge t no worse or ac tua l l y improve ove r t i me ( H o c h b e rg
1 996)
Seve ral s t u dies have fo llowed up p a ti e n ts w i th knee OA for a b ou t a decade or more . I n o ne study t w e n t y paLients with OA knee go t worse , seve n re m a i n e d the s a m e a nd fou r gOl be tte r ( M ass a rd o et a l .
1 989)
I n a l ong- term study, 5 7 % o f p a t ie n t s reponed a worsening
o f symp toms , bu t 2 5 % w e re unc ha n ged and 1 8 % were i m p roved (Hernborg and N i lsson
1 9 7 7) In a n o t h e r stu d y
with a n e l even-ye a r
fo l l ow- u p , l e s s t ha n ha l f t h e p a t i e n t s s h o w e d a w o rs e n i n g o f r a d i o gra p hi c fin d ings , wh i l e ab o u t 1 0 % s ho w e d i m p ro v e m e n t .
Although ha l f tho ught their pain had worsene d , their v i s u a l a na l ogue pain scales were the same , and those re po rting knee p a in declined from 69% to 52% (Spector e t a 1 .
1 992) .
These a u t h o rs concl u d e d ,
" I t appears that the lo ng- term progn O S i s in
a
l a rge p rop o r t i o n of
pati ents w i t h os teoarthri tis i s good. Only a m i n o r i ty a re l i k e ly to p rogress rapidly and have a deteri o rati o n in th e i r knee sy mptom s . "
OA i s ne i th e r an i n evitable part of the agei ng p ro c ess nor necessar i l y progressive . While abo u t 5 0 % o f those o v e r 60 have sym p t o ms o f
OA, this proportion remains reasona b ly s t a b l e t h ro ugh the 7 0 s , 80s and 9 0s (Forma n et a 1 . The h a n d s
,
1 983)
fe e t , kne e s a n d hips are t he pe ri p h e ra l j o i n t s m o s t
commonly a ffe c t e d by d e genera tive change s . Ankles and shou l d e rs a re involved less freque n tly, and elb ows and w ri s t s on ly occasi o na ll y (Pe t e rsson
1996;
H u s k i ss o n and H a r t
1 9 8 7)
T h e c a u s e o f t h.is
p re d i l e c t i o n fo r c e r t a i n j o i nt s is u n k no w l1 . I t is c o m m o n for i n d ividuals La b e a ffected in several site s .
O A is ch a r a c t erise d by a reas o f local d e s t ru c t i o n o f t h e a rtic u l a r cartilage and re modelling o f the s u b c h o nd ra l bone I f the J oi n t damage is extensive enough these c h a nges are seen o n x - ra y as narro w i n g o f the j O int , s c l e rosis o f t h e b o ne a n d growth o f osteo phytes M u c h o f t h e pa t hol ogy o f OA i s s e e n as an a ttempt a t repair, o r an aberra n t version o f t he same . T he articu lar ca r ti la ge which i s the mai n targe t ,
tissue of OA , is devo i d of nerve endings whic h m a y explain the lack of pain in many p a t i e n ts , especia l ly those with o nly mild disease (McCarthy et a1.
1 99 4 ;
Hu skisson and Hart
1 987)
Pain is thought to a rise from t he subchond ra l b O l1e , p e r i o s te u m , synov1u m , ca psu le a nd liga m ents resulting fro m abnorma l mec h.anica l stresses o n the p e ri - a r ticular s t ru c tu re s . I n i t i a l l y t h e re is aching o f
COMMON
D I S C)lt D E RS
C H A rT E R TEN
j o ints at rest o ften re l i eved by m ovement . As the disorder d evelops pai n becomes re lated to use , being especi ally n o ticeable o n ini tiation o f move men t or weight-bearing. T here is fibrosis , thickening and contracture o f the ca psule causing s t i ffness , red uced movement a nd pain a t the end of range Restric ted venous o u t fl ow causing stasis and conge s t i o n can also be a fac t o r in pain p roduction. Abe rrant load i n g can cause e xcessi ve mechanical strain on ligaments , possibly lead ing to micro-trauma. At the more extreme end of the continuum of pathol ogical changes [·ragme n tation of t he ca rti lage or bone can lead to the formati on o f i n tra-arti c u l a r bodies that may cause mechanical o r in flamma tory symptoms d u e to nli tation o f t h e synoviu m . There may be episodes o f inflam mation d u e to syno v i tis , causing a constant chem ical pain . N o x i o u s slimu l i fro m d iseased j o i n ts can cause inhibition o f motor neurones l e a d ing to weakness and muscle atrophy Muscle weakness and d a mage to ligame n ts may i n d u c e u n s ta b l e j o ints t h a t a re vu l nerable t o trau m a , a n d thus prone to episodes o f acute inj u ry, inflammation a n d post-traumatic pain . Persistent p a in can lead to se nsitisa tion at local and cen tral l evels resulting in a l owering o f the pain th reshold (McCarthy
et
al. 1 99 4 ; Huskisson and H a rt 1 98 7 ;
Preid le r e t a t . 1 9 9 6 ; Akeson
et
al . 1 9 89 ; Thre l keld a n d Cu rrier 1 9 8 8 ;
Ma rks 1 99 2 ) T he cause o f s y m p t o m s from degenerative conditions is there fo re mu l t i faCloria l , a n d re prese n ts a spec tru m inv o l ving m e chanica l , i n f1am mato ry, isc haemic and other fac t o rs . I t i s suggested that O A is not in fact
a
s i ngl e disease , b u t is an um bre lla term for a range o f
similar con d i ti o n s w h ose aetiol ogy may b e primarily systemic or biomechan ical (Dieppe and Ki rwan 1 9 94) It is quite likely under these c i rcumstances t h a t d i fferent presen t a t i ons may respond to d i ffe rent manage ment stra tegies. Some pa tients having symptoms from OA may presen t with p u rely mechanical probl ems - for instance , end -ra n ge capsula r s tretc hing reveals limitation and pain . In other pa tients n o n - m ec h a n ic a l fac t o rs m a y be p a r a m o u n t . As i n all p e r s i s t e n t t i s s u e a b n o r m a l i t y t h e role of s e n s i t i s a t i o n a n d deconditioning fro m lack o f n ormal use shoul d b e co nsid e red . M a n agement of dege nerative j o i nt c o n d i t i o n s
M a n a g e me n t gU i d e l i n es fo r OA fre q u en t l y s t re s s the va l u e of educa tion a n d exerc ises (McCarthy
et
aL 1994; Dieppe 1 9 9 3 , 1 99 5 ;
H ochberg 1 9 9 5 a , 1 99 5 b) Exercise is the o n ly p hysical m o dality that
1 257
258 1 C H A PT E R T E N
T H E H U M A N E X T R E M I T I E S : M E CHA N I C A L D I A G N O S I S & TH E R A I'Y
has consistently been found to be valuable in the m a n a ge m e n t of OA (Clarke 1 9 9 9 ) . A ' p y ramid' a pp ro a c h to the m anagem e n t o f OA has b e e n p ro p o s e d , in w h i c h a l l p a t ie n ts s h o u l d h a ve a c c e ss to i n terve ntions at the base o f the pyramid , whe reas onl y the few with the severest symptom will need those at the apex (D ieppe 1 9 9 5 ; H ochberg 1 9 9 5 a , 1 9 9 5b) Management s t r at e g i e s t o b e used w i th t h e m a j o r i ty o f p a t i e n t s i n c l u d e e d u c a t i o n , c o u n s e l l i n g
,
empowe rmen t , exe rcise s , s ti.cks , physiothera py a n d ana l gesics . A mino rity o f p a t i ents may need NSAlDs , hydro therapy a n d mo re c omplex aids, while
a
few will need su rge ry (Dieppe 1 9 9 5 )
The therapeutic v a l u e o f N SAlDs f o r OA is not clea r cl esp ite their rou tme use . OA frequently has only a mi n o r i nOam m a t o ry co m p o n e n t
( D i e p pe et a l . 1 9 9 3 ) I e a p pears L h a L simple a na l gesics a re a s good a s .
N S A I D s (Towheed et al . 1 9 9 9 ; D i e p p e 1 9 9 3 ; M c C a rLhy e t a l . 1 994) Brad ley e t a l . ( 1 9 9 1 ) c o m par e d i bu p ro fen a t a n anti- i n fl a mmatory and p ure ly a na lgesic dosage , and acetami n o p hen ( p u re l y an a n a l ge s i c )
and fou n d tha t all three groups had imp ro v e me nts
i n maj or O U l c o m es
,
which were n o n - s ign i fi c a n t b e t w e e n the gro u p s . C o m p a riso n s between N SAlDs a n d place bos o r analgesics are co nsidera b l y less rese a rched tha n comparisons b e tween di f fe re n t NSAlDs.
It
wo u l d
appe ar that the d ru g com p a n ies are happier fun d i n g c o m p a ra t ive stu dies between di ffe rent N SA l Ds than c o m p ar ing t h e m to much less costly analges i cs , let alone non- p h a rmacologi c a l interventions (Dieppe et al. 1 9 9 3 ) n l e re is a ls o
co
n c e rn that the re is b i a s e d
i n t e rp retation o f resu lts in fa v o u r o f a c e rt a i n p ro d u c t in t r i a l s associa ted w i th drug manu facturers ( Ro c h on et a l . 1 9 9 4 ) NSAlDs a r e also as so c i a t e d with considerable mo rbi d i ty a n d mortal ity
d u e to gastrointes tinal d a m a ge . A m e ta - an a l y s i s c on c lu d e d tha t N SAID users a re three t i m e s more like ly to d e ve lop serious adverse gastrointestinal events than non-users ( G a b ri e l et a l . 1 9 9 1) It is estima ted that 20
-
3 0 % of all hospita l isations a n d deaths i n t he
ov er 65 s are d u e to p e p t i c u lcer disease attributa ble to N S A l D thera p y -
( H ochberg 1 9 9 5 a ; B a ko w s k y and Hanley 1 9 9 9 ) . l L is estimated t h a t there are ab out 2 0 0 deaths a ye ar J u st i n t he UK attrib u table to their
use (Somerville et al. 1 9 86) , and tha t t h ey acco u n t for 2 5 % o f all d rug side effects (Rochon et al. 1 9 94) Because o f the n u m b e rs of people using N SAlDs worldwide - 30 mil lion people are t h ought t o use them every day - adverse events a r i s i n g from the ir use a re more frequent than with any other fo rm o f d rug treatme n t (Gabrie l and Bombadier 1 99 0 ; Haslock 1 9 90) As a c o n se q u e n c e o f this d ebate it
C O M M O N D I S O R D E RS
C H A PT E R T E N
is s u ggested t hat d ru g s , o f ten o f the wron g s o r t , a re overused , whereas biomec h a n ical inte rventions for the management of OA are unde rused
( D i e pp e 1 9 9 3 ) A p o si t i v e a l t i t u d e t o w a rd s p a tients w i t h this c o n d i t i on is warran ted as s y m p toms o f t e n stabi l ise o r imp rove , and there is n o t ne c e ss a r il y an i n ev i ta b le progression w i th i ncreasing morb i d i t y and disability. Ano t h e r o f the my ths o f OA
-
thal c ar t i l age c a n n o t re pa ir i tself
-
is
d i s p ro ve d by c o n te m p o ra ry e v i d ence (Bland 1 9 9 3 ; M c C a rt hy et al. 1 9 9 4) It 1S importan t to try to ' d e - m e d i ca l is e ' th e c o n d i tion , reassure a b o u t t h e pro g n o s i s , and e nc o u r age c o n t rol and e m p o w e rment (Dieppe 1 9 95)
As in all c h r o n i c d i seases the p a t i e n t has certain
res p onsi bi l i t i e s
-
to l e a r n ab o u t the c on d i ti o n , t o ta k e c e r t a i n
re spo nsibi l i ti es , a n d eva luate t he heal t h care e xperien c e ( B r a dy 1 9 98) .
Cu r rent me t a - an a ly sis o f s t u di e s suggests tha t p a ti e n t edu cation fo r rh e u m a t o l o g ic a l c o n d i t i ons c a n a ffe ct k n ow le d ge , p a i n , J oint c o u n ts , d e p re SSi o n , e xercise a n d c o p ing behaviours , wi t h se l f- e ffi cacy and
s o c i a l s u p p ort a p pearing t o be s t ro n g causa l mechanisms for these
bene fi ts (Lo rish and
B o u t a gh 1 9 9 7 ) I nc r eas e d self-effica cy, which is
the pa t i e n t s s e nse o f ab i li ty to a ffe c t the c ons e q u e nc es o f d isease , '
i mpro ve o t he r o u tco m es such as pain and d i sa bi li. t y (L o r i g et al . 1 9 89) F o r instanc e , indi v i du a l ised progr a mme s i nv ol ving exercise , re l a xa t i o n , ap pro p ri a t e use o f a ffe cted j oi n ts a nd p roblem- s o l vi n g re s u l t e d i n better functional p res e rva t i on , imp ro ved pain , fewer health c a re v is i t s and l e ss d e pre ssion
( L o r i g and Holman 1 9 8 9 ; Lori g
et
al.
1 9 9 3 ; Mazzuca e t al . 1 9 9 7 ) The clini ci a n s role is obviously to o ffer '
info rm a t i o n abo u t t h e c o n d i tio n a n d sel f-management strategies tha t
will a f fe c t i ts consequences. A sy s te m a t i c re v i e w of non - i n va si v e s tu d i e s into t h e rapies fo r OA o f t he h i p and knee fo und that exercise re d u ces pain and i m p roves fu n c t i o n in p a t i e n ts w i t h knee OA, but genera l ly fai l e d to su p p o r t p a s s i v e tre a tm e n t m o d a li ties . N o s t u d i e s were fo un d b y t h i s group that evaluated exe rcise for OA of th e hip. Of th e 600 artic l e s they i n i t i a l l y review e d o v e r 60% re lated t o tr e a t me nt by NSAl D s , whi l e
only 5 % l o o k e d a t non-m e d i cal eva l u a t i ons (Puett and Gri ffi n 1 9 94) .
S i n c e t h e n a u i a l c o m p a rin g m e d i c a tio n and e d u c a ti on with o r wi tho m su p p l e ment ary
e x e rcis es
for OA hips a n d knees foun d tha t
the exe rcise group , a ft er twelve weeks , had gre a t e r i m p r o vem e n t s in r e d u c t i o n of p a i n a n d d i s ab i l i t y ( v an B a a r e t a l . 1 9 9 8 b )
H ome
exe rci ses fo r the h i p a re as e ffe ctive as o u tpali en t hy d ro th e ra py ( G ree n
1 259
260
I C H A PT E R T E N
TH E
H UMAN
E X T R E M I T I E S : M E C H A N I CA L D I AG N O S I S & T I- H RA rY
et a l . 1 9 9 3 ) A n o th e r w i d e - rangi ng re view a l s o found li t tl e e v i d ence i n fa vou r o f p a ssi v e tre a tment modali t ies , but c o n s i s t e n t v a l u e in s trengt h e n i n g e x e rc is es fo r the knee (Clarke 1 99 9 ) An example is a su pe r v i se d fi tness walking and e d u ca t i o n p rogra mme t ha t i m p roved
fu nctio nal s t a tu s and pain , and re d u c e cl me d ica t i o n use c o m p ared to a contro l grou p (Kov a r et aL 1 9 9 2 )
Part i c i pa t i o n in e i t he r a n
a e rob i c o r resi s t a n ce exe rcises p ro g r a m m e b r o u g h t a b o u t i m p rovements i n m e a s u res o f disa b il i t y, physical pe r ro r m an ce and
pain compared to an e d u ca tion progra m m e ( E t ti nge r
et
al. 1 9 9 7)
Main t a i n i ng a fu ll ra n g e o f m ov e m e n t a n d musc l e strength a L a n a ffe c t e d J o i n t m a y re d u c e disease p ro greS S i o n a s w e l l a s g r e a t l y decreaSing p a i n and disabili ty ( D i e p p e 1 9 9 5 ; M cCa rt hy et a l . 1 9 9 4 : Fisher e t al . 1 9 9 1) S e l f- m a n a g e m e n t exercises
Patients with degenera tive J o i n t cond itions may present with restric t e d m o vements w i t h p a in a t t he end o f r a n ge . T h is i s d u e t o capsu l a r thicke n i n g a n d contracture o f t h e J o i n t ca psule ( M c C a r t h y e t a l .
1 9 94) This contra c tion and loss o f e lastic i t y causes d y s functi o n , a n d i n m a ny cases even sma l l i mprovement i n the ran ge o f mot i o n
c a n resu l t i n reduction o f pain I m pro v e m e n ts a re e s p e c i a l l y p ossible w h e n the e n d - range fee l s p lastic rath e r than l i k e c o n c re t e .
I
Photos 1 04.
1 05
Different metbods of se!fmob ilisation into knee extension, with or witho u t oue,pressure. Pressure on, pressure off, t e n limes.
1 05
1 04
C O M M O N D I S O R D E R.S
C i-IA I'T E R T E N
Photos l Ou, 1 0 7, l OR Differell/ me/bods of setlmobilisatio n into bip flexion with overpressu re. Pressure O l l) pressure o.h: leJl tirnes.
106
1 08
/1) 7
Th ese p ro b l e m s a re m o s t c o m m o n l y seen
in patients
wi th k n e e a n d
h i p O A In h i p O A d iffe re n t p a t t e rns o f radiol ogica l a n d p a t h o lo gical c h a nges have b e e n observed (Cam e ron and Macnab 1 9 7 5 )
They
rou n d Lhal 40% of p a t ients had early and marked capsular restricti on , w h i l e in L h e re s t capsu lar re s t liction was m i n i m a l unti l th e re were
g ro ss d e genera tive change s . It is sugges ted t h a t the capsu lar c hanges a re sign i fi c a n t i n th e p rog re ss i o n 0 1- the c o n d i tion (Camero n and M a cnab 1 9 7 5 ) At t he knee p a t ients mus t be enc o u raged to regain and m a i nta i n e x t e ns i o n , hype rextens i o n a n d Hexio n . A t the hip the key m ov e m e nLS a re aga i n flexion and e x tens i o n but a l so ful l range ,
of m e d ia l ro t a L i o n a n d a b du c t i on are c ommonly l o s t (Dieppe 1 9 9 5 ) Se l f- m a nage m e n t exerc i ses can be s u p p l e m e n te d by a s h o rt c o u rse of c l i n i c i a n m o bi l is a t ions , w it h media l r o t a t io n at the hip sometimes
being d i ffi c u l t for the p a t i e n t to do ade q u a tely l n d i v idual pat ients
1 261
1
262 C H A rT E R
TEN
TH E
1 09
H U M A N E X T R E M I T I E S : M E C H A N I CA L D I A G N O S I S & T i l E R-MY
111 Photos 1 09, 1 1 0,
11I
Differe n t methods oJ self l l lO iJilisCI /iol1 illto h ip extension u 'itb ouerpressure, bilateral II l I d u n ila t e m /.
Pressure on,
pressure
off
fen lillles.
/ /0
Pho to 1 1 2 111 /"rnol ro tation oj the hip, with ur witho ut o l 'erpressure. Pressure on, pressure oJf, ten times.
present w i th va ri a ti o ns o f m o ve me n t l o ss and the p a r t ic u l a r m o v e m e n t s t h a t must be p r a c t ised s hould b e d e c i d e d b y phys i c a l examina llon ra the r than t h e o re t ica l p resc r i p t i o n P a t i e n ts w ill need to do the exe rc i ses w i t h over p re ss u re s e v e r a l t i m e s daily u n t i l i mp roved m o bil i t y p ro d u ces a n i m p rovement i n s y m p t o ms Afte r t h i s , e x e rc i s e s s h o u l d be d o ne o n a daily basis LO mainta i n the c h ange The previo us ana lysis o f the evidence makes it c le a r t h a t a ge neral strengthe ning o r exercise p rogra m m e is a v i tal pa rt o f the ongoing sel f-management of this c o n d i t i on A l l patients sho u l d be a d v i s e d o n t h e v a l u e o f p e d o r m i n g s u c h
a
p rogramm e , and c l i n i c i a n s s h o u l d advise and d iscuss w i t h pa tients the pra c t i c a l i t i e s a n d p ro b l e ms o f s o d o i n g .
/ /2
'
C OJI/\ Iv\ O N
D I S O rW E R S
C H A rT E R T E N
Assess m e n t
Fi g u re 1 0 . 6
sheet - hip j oint
OA
TH E M c K E N Z I E I N STITUTE P E R I P H E R A L A S S E SS M E N T
.I . .
. . . . . . .I . .
Date
Name
Address
J.
. . . . . . .1 .
Date of birth Postures J
Stresses
:8c \!J\�
. .
. . . . . . �\V<jl
Functio n a l
. . . .B'I-. . �\:t.
..
. :':l\I.I:\�
.
6\.. � rL\-:::'
.. .
from present
disability
. �B
Age
.J �:X-.<X. ) ',...'1�
Work ( leisure . . . . .�\"b
episode
SYMPTOMS
LC'.G\D�
�ce:d
H I STORY ..
P r e s e n t symptoms
�I;- . �c)\D, . . . . OW\\C::C.�.. )
res u l t
C o m m e n c e d as a
\O CC'CDn:s
........ i..
.. .1
.
Presen\ s i n c e
of .
S y m p to ms at o n s et I n t e rm ittent s y m ptoms
C o n s t a n t s y m ptoms W h a t produces o r
B\\e.s
worsens <.00 \K\ D q
�::)\� � ) .
C o n t i n u e d u s e makes the
P a i n at
Yes
rest
Other
q u es tions .
Treatment
Previous
this
episode
episodes
.
. .
pain
No
Better
..
.
�O\e..I;- :S . . Qcce. . .
B-6_:f:H::'U ::::, �\;:::, � e¥ CC:l t::::e::.::::.. . �'D \D xc."5)\ . . ,_>..e:c"3C . .
Me dicat i o n s :
....
General I maging
S ites for
Paraesthesia
Yes
®
p h y s i a l e x a m i n ation .
. c..res::-:qe �"' . . . . . . L......i� . . ;:'J?\DC- . . tf.. . . .'c-c,b . h,p.:5 Trauma �di O US � I�
'.�-e .
Acute J Sub-acute
c
e . CQ .e�J.
. . .�. . .
�cd
.. �es:. . . .::.":>\)�
S u m m a ry :
�C..r �iO J "'bO 0 d;�� ,
E H ct
tried c\-� \ D. . .
d health
P rese n t m e ica t io n
EHect
�..
P revious treat m e n t . S p i n a l h i s t o ry
-D\ ID\e..C\X"'Il\1c. <:"ccxD
• .
� Yes
Disturbed night
IOt1'C"l\
. e"\\\ . .
\9 . (X.;l. ro<..0 (?": X?E:<..u . �ceci l \,:Cd6) u.::;e: '� �(L� , . . . . . �uolbr-h:J
�
o
1 263
264 1 C H APTE R T E N
T I-I E H U M A N E X T R E M I T I E S : M E C H A N I C A L D I A G N O S I S & T H E R A P Y
P E R I P H ERAL Observation .
,
. P O M ... ....... ... ..
Active movement Loss .
Passive m o v e m e n t Loss
.. E R P ..
POM..
.
.. ............ E R P .
( +I-over-pressu re)
. F�xiC:C\ .
.
. .
.
. . .
;.
E::R. p
0" O \ �\ \o;:::,� E:;€.P j . . \ 5<> .
Bb6.u.C:h 00
. . . . . . .
C\'ed, "C) \ \C �t1 ,::::C\
.
\aD �
.
�.
BO'dl....l c±,CI:"\ S?e.K.\CC\
. .
.
\o�
R e s i s t e d tests Response .
. . . . . . . . ......D8D .. prod uces,
EHect o f repea ted tests o n pa i n :
radiates,
better,
worse,
. . .. po;:.x:1uc.ed
. . . . . �)QC:CI .
decreases ,
i n crea s e s ,
abolish e s , loca l ises,
�\8l.\ cr::::>t a�C£":)
n o better,
. . . . . . . OOt
. podu ced
.
. 1X::l .t
Belter
EHect o f repeated tests on mov e m e n t :
Worse
St a t i c Positio n i n g EHects
Loaded I U n l oaded . .
SPINE
.
Movement loss
:;'\
elUeD ;::- c::f':\
. . .
)
�� /
Q\ OC
� �\ \ d.\n<"l
EHect of repeated movements: .
EHect of s t a t i c p o s i t i o n i n g : .
G
�
ot relev
S p i n e tes t i n g :
CONCLUSION
$SfU;� ®icula:0
R e l e v a n t I Seco n d a ry problem
H \p
�
e:ocl,--\ Of'\
Spine . C o n t ra c t i l e
?
Derangement
Postural
Oth e r .
U n c e rt a i n
P LAN E x e rc i s e
Frequency
. :'1: . . .D P . .. . . '10 ICY . �ya\ , \D\a-\1 cC\ . , . �t aP
, .'+�\C::C'I
.
.
. ..
.
.
.
. . x . . . 10
.
Y ..
. . . .
� It±X 0/t+
no
w ors e
,
n o eHect
.
LCXY.� . . .
L\SOoJ. 3e:.
. .
�
C O M M O N D l s o lZ D E R S
C H A I'T E R
Lateral an kle spra ins An k le i nj u r i e s a re c o m m on o ccu r re n ce s ; 5 , 0 0 0 a re e s n m a t e d t o hap p e n every d a y i n t h e U K a n d 2 3 , 0 0 0 every d ay i n the U S . La teral s p ra ins c o nstitu te ove r 90% of tra u m a to ankles . I n di v i d u als wh o s p ra i n t h e i r a n kles frequently a t tend hospital accident and emergency d e p a rtments . T h e y co n s ti tu t e 7
-
1 0 % o f those examined in
e m e rge n c y d e p a r t ments i n Scand i n a v i a n h o s p i tals , a n d o v e r 3 % o f t hose vis i ti ng a n e m e rge ncy d e p a rtmen t i n a U K h o s p i ta l . Ank l e s p ra i ns always h a v e a t rau m a t i c o nse t , t he y a re o ften s p o n s -related i nj u ries , a n d as a c o nse qu ence the most c o m mon age gro u p for this c o nd i t i o n is under 3 5 . T he y cons t i tu te over 2 % of pa tients seen by D u tc h p hYSiotherapists , 6 % of m us c u l oskeletal p roblems a ttending G P c l i n i c s i n t h e U K , and 20% of th ose a ttend ing a n o rtho p aedic o u tpatie n t d e pa r t m e n t . Recu r re n t i nj u ries to the ankle a re c o m mo n
(Ha c k e t t e L a l . 1 9 93 ; H ockin a n d Bannister 1 9 9 4 ; S i m p s o n 1 9 9 1 ; Kan nus a n d Rens t ro m 1 9 9 1 ; Roeb roeck e t a!. 1 9 9 8 ; D u n l o p e t a ! .
1 9 86) O f t h ose a t t e n d i ng a c c i d e n t and e m e rgency depa rtments , b e tween 1 6 % a n d 3 0 % have s u s ta i n e d a fractu re , either in the ma lleolar region, around the fi fth m e t a t a rsa l , o r a vulsi on fra c t u res . Pain and b o n e L e n d e r n ess a l c e n a i n s i les a n d ina b i l i ty to b e a r weigh t a re i m p ortan t cl i n i c a l v a r iab les in p re d i c t i n g important fra c t u res , and have been fo rm u l a ted as g u i d e l i n es t"o r sel e c tive radiographi C exa m ination of th ese p a L i e nts ( D u n l o p e t a / . 1 9 8 6 ; S tiel l e t a/. 1 9 9 5 ) Only a small p ro p o rti o n of p a t i e n ts had frac t u res that were n o t d e tected on their
init i a l assess m e n L a t the hos p i ta l . Th e most c o m mo n s i tes o f s o [t tissu e sp ra i ns of the ankle a re a t the a n terior ta l o fi b u la r l iga m e n t , w i th m o re severe trau ma also involvi n g the ca l c a n e o fi b u l a r l i ga me n t ( K a n n u s a n d Renstrom 1 9 9 1 ; M o l le r La rsen e t a l . 1 9 88) The seve n ty o f the inj U ry can vary fro m sligh t tearing to c o m p l e te ru p tu re and gross i n s t a b i l i t y a t t h e ankle J oi n t . The p r e v a l e n c e ra te o f t h e m ore extreme i nj u ries ap p e a rs t o b e u nk n o w n . M a n a g e m e n t of l i ga me n t r u ptu res a n d s p ra i n s
The evidence pro v ided by past tria ls a n d reviews o f these studies is v e r y cle a r in i t s reco m m e n d a t i o ns Even fo r c o m p l e te ru p t u re of the l i ga me n t a review of the literature rec ommends conservative treatment
w i th e a r l y func tional rehabilitati o n (Kannus and Renstrom 1 9 9 1 )
TEN
1 265
266
1 C H A PT E R T E N
TH E H U MAN
EXTREMITI ES:
M E C H A N I C A L D I AG N O S I S &
TH E RAPY
In the trials re viewed , 7 5 - 1 00 % o f patie nts h a d good o u tco mes a t o n e year w h e t h e r trea t e d by re p a i r and c as t , caSl a l one o r e a rl y c o n tro l i e d mob ilisation . A s h o r t p e r iod o f p ro te c t i o n , e a rly we igh t bearing a n d range o f movement exercises , followed by neu rom usc u l a r training o f the a n k le p rovides the quickest recove ry to fu l l fu nc ti o n , and is no m o re asso c i a t e d w i th com promise o f a n k l e stab ili ty than other in terventions (Kannus a n d Rens t rom 1 9 9 1 ; B o ru ta e t al. 1 9 9 0 ; Ogi l v i e - H a rris a n d G i l b a r t 1 9 9 5 ; Re n s tro m a n d Ko n r a clson 1 9 9 7) Pa tients w i th less severe t e a rs o f t he l igame nt recover q u i c k ly w i th
a
short p e ri o d o f i mmob ilisatio n , RICE p ro to c o l and p ro te c t i o n (see Lind s a y e t al. 1 9 9 4 ) , e a r l y a c t i v e ra nge of m o v e me n t e x e rcis e s , followed b y weight - beari n g strengthening a n d p roprioce p t i v e t raining
( K a n nu s a n d Renstrom 1 9 9 1 ; O g i l v i e - H a r r i s and G i l b a rt 1 9 9 5 ; Renstro m a n d Konradson 1 9 9 7 ; Shrier 1 9 9 5 ) U sing this manage m e n t s tra tegy w i t h inj u red army c a d e ts produ c e d periods o f d isabi l i t y o f o ne to t w o wee k s o n l y Q a c kson et al. 1 9 7 4 ) E a r l y m o b i l isat i o n , c o m p a re d t o i mmobili s a t i o n i n plas ter, o ffe rs t h e most rapid re t u rn to n o rma l func tional ac tivity (Bro o ks et al 1 98 1) I c e in the fi rs t few d a ys is as effe c t ive as N SAID to reduce p a i n and oedema a n d p romote e a rly re covery, w h il e there i s limited e v i d e n c e t o su p p o rt the use o f u l t ra s o u n d (Ogilvie -Harris and Gilb a r t 1 9 9 5 ) I n a n a c u t e grou p o f pa tients wi th l a t e ral l igame nt sp rains , u l tr a so u n d w a s no better tha n place b o a t re d U C ing p a i n a n d sw e l l i n g , and i m p rov i n g fu nc t i o n (Nya nzi et a l . 1 9 99)
I t is wid ely a gre e d that wi l h t h i s e a rl y a c t i v e
m a n a gement re covery i s fa st and the prognosis is goo d ( Re n s tro m a n d Konra d s o n 1 99 7) Medic a l a n d p hysiothe rapy ma nagemen t o f this c o n d i t i o n does n o t a lways o ffer t h i s op timal strategy to recovery P re - physi o t h e ra p y many p a t ie n t s a re g i v e n no a d vice a t a l l , or if they a re t h i s i s o ft e n inappropriate , involvi ng rest or non-wei ght-b earing exe rcise (S impson
1 9 9 1 ) . In
t h e US when surveyed a b o u t th e i r manage m e n t o f t h i s
p ro b l e m , d o c t o rs s o m e t i m e s n e g l e c t e d a d v i c e o n re s t , i c e , c o m p re s s i o n a n d e l e v a t i o n , a n d fre q u e n t l y fa i l e d t o p ro v i d e rehab ilitation exercises (Kay 1 985) . Al though Du t c h phys i o t h e ra p Ists use p r ogress i v e l y more e x e rc i s e t h era p y o v e r the d ur a t i o n o f treatmen t , u l t ra s o u n d and short-wave therapy a re s till used i n the l a s t phase of tre a t m en t , and adv ice on activ ities and home exe rcises were a t no p o i n t given to m o re than 1 5 % of p a t i e n ts (Roebroeck et al. 1 99 8 ) .
C H A P TE R
C O M M O N D I S O R D E RS
Self-ma n a g e m e nt
I f p a t i e nt s
a r e s e e n e a r l y, m a n a ge m e n t
p ro gresses t h r o u g h the
fo l l o w in g s t a ges
Day 1 D ay
Res t , ice , co m p ress i o n , e le v a t i on
(RI CE) .
As Day 1 , p lus n o n -weigh t - b earing range o f m o ve m e n t
2
e x e rcises , walk i n g .
Vle e k
1
-
N o n - w e i g h t - b e a ring range o f moveme n t a n d i so me tri c exerc ises ; possibly e a r ly weight -be a ring e x e rcise s .
Wee k 2
-
Weigh t - b e a ring exercises , progress s t re tc h i n g exercise s , e a r l y b alance exercises .
Wee k 3
-
Progress w e i g h t-bearing exercise s , s tre tchin g exercises , b a l ance e x e rcises , s t re n gthening exercises .
Wee k 4
-
F u n c t iona l rehabi l i t a t io n .
T h e e x a c t t i me scale that p a t ie n t s progress a t d epends o n the seve r i ty o f the
injury
a n d their response to
exercise.
These times p rovi d e a
ro ugh g u i d e only (see a lso Lindsay et a l . 1 9 9 4 ) Exerc ises n e e d t o stress t he d a maged ligament us ing a p rogression o f fo rces . These can be d o n e firs t actively a n d unl o a d e d .
F o r a s t ro n ger s t retch in the c h r o n i c s tage , get the p a tient to use b o th
hands t o s t re t c h i n t o p l a n t a r- fle X i o n and inversi o n , w hich should re p ro d u ce the p a l ie m s pain . Progressions inv olve w e ight-b e a r i ng '
Pli%
s 1 1 3. I 1 4 lInlouded actioe /Il ooements i n lateral ankle sprain. Starting from a neutral jJosili(J1I the jJalienl J/UJl les into i}wersiolJ ten times. They should stretc/J further and /Il ore forcefUlly each day. Earl)!
l l3
1 14
TEN
1 267
268 1 C H A PT E R T E N
T H E H U M A N E X T R E M I T I E S : M E C H A N I CA L
D I A G N O S I S & T H E R A I' Y
e x e rcises , i n i t i a l l y i n b a re feet and then with s ho e s , whic h i n
a
con t roll e d way stress the l a teral l i gamen t . We ight-bearing in ve rsi o n s h o u l d fi rst be p e rfo rme d on the a ffe c te d foo t o n l y, 'vv i th the s o u n d le g p rovidin g support L a t e r t h is c an be pe r fo r med o n bOlh fee t , a ncl then in shoes . Pbolos 1 1 5, 1 1 6: 1 1 7, 1 1 8 oj loaded il1l'ersio/'l stress jo r la tera/ liga m e n t sfrain (/1 fhe (l nkle. Slar/ with joot flat, then the patie n t repeatedly inller/s Ibe joot fen lilll es. ('{//Ising eccentric and con centric loading. Pe,pJrmillg tbe exercise oila/emll)' can iJe easier To progress fbe exercises, INljonn tbe same exercise in sboes.
Progressioll
1 15
116
117
1 18
COMMON
C H APT E R.
D I S O R D E RS
Pa t i e n ls w h o p re s e n t at a l a t e s t a ge m a y w e l l d i s p l a y signs o f dysfunction o f t i1e a ffected liga m e n t N o h i st o l o gi c a l changes h ave been fo u n d in c h ro n i c l i gament pro blems except scarring (Renstrom and K o nradson 1 9 9 7 ) F o l l owing the a c u t e i n flam m a tory stage , ad hesions may have been a llowf.d t o develop and now prevent fu ll
r3 nge p l a n ta r-fl exio n , invers i o n , a n d med ial rotation o f the fo o t . The
a pp ro p riate se l f-s tretches a n d l o a d i ng exercises as o u tlined a b ove shou l d be perfo rmed
Recu r re n t a n k l e sprains a re common ( S i m p s o n 1 99 1 ) . Those w h o h a ve had p re v i o us a n k l e spra ins a re twice as likel y to have ano ther
inj ury c o m p a re d to those with n o previous history ( Tro p p
This
et
al. 1 985) .
m ay be d u e to d e c reased p ro p ri o ce p t i o n and/or p e r i n e a l
weakness ( B o y l e a nd N egus 1 9 9 8 ; Baruta
et
al. 1 9 9 0 ) . B a l a n c e
e xerc i s e s , w o b b l e - boa rd w o rk and ge neral s trengthening o f muscles 3 round the a n k l e a re there fore an essential part of rehabilita tion and p ro p h y l a X i S aga i nst fu t u re sprains Patients can perform approp ri ate
exercises a t h o m e b y standing on one leg with eyes close d , walking o n t i p toes a nd hee ls , e t c . Pe rsistent prob lems of functional instab ility
wil l be a v o i de d i n many p a tients i f they are p r o p e rly reh abilitated
(Renstro m a n d Kon radson 1 9 9 7)
In
a thletes , several months o f
c o o rd i na t i o n t ra i n ing o r u s e o f a n o rt h osis h a d the effect o f re ducing re cu rre n ces drama tical ly, so t h a t the incide nce of recurrences was reduced to that of p rima ry inj uries (Trop p et al. 1 985) . Such treatment shou l d be i n s t igated fo r all patients , wheth e r they are seen with an acu t e or c h ro n i c p roblem .
TEN
1 269
270 1 C H A PT E R T E N F i g u re 1 0 . 7
H U MAN
TH E
Assessment s h e e t
-
E X T R E M I T I E S : M E C H A N I C A L D I AG N O S I S & T H E RA ! 'Y
ankle inversion spra i n
TH E M c K E NZI E I N STITUTE P E R I P H ERAL ASSESSM ENT
Date Name
. . . .. . . . . / . . . . . . . . .1 . .
Address
/
Date of birth Work
/
Postures
/
.... ..
/ ....
. . .4-0 .. .
Age
fte,T aW<:.e. i O�u:.
L e i s u re
U.:::C::C'c:..
Q\\\:IC'CI; \'()�:\\'"'"'\ �\W� ) . 6tEp -ae.CC::'\;� \�
S t resses
.... .. .....
Funct i o n a l d i s a b i l ity from p resent episode
..
oW· �'):. oW tSfOC-\-
· · ·· · ··············· ·····
SYM PTOMS H I STO RY
.....
8\qb-\- \��B\ . . . 2�-:-:·)t..\e.. ./ roc:>\
.
P res e n t s y m pt o m s Present s i n c e
. .1 . . . . . . J
C o m menced a s a res u l t of
5
lJ-.,��
w\�
.
9W . 6:\E:p. .
\ �i.:�'te- �\(:'.. C"
Sym ptoms a t o n s e t
.
C
)
l m prOVing
&" \C\� te.d
aD'l::.�/ ., ra a-\ i
U n ch a n g i n g
/
Worsen i n g
or n o apparent reason
u.CGb\<e. to ��'r : beu- ;
symptoms cpQfD Jf �'-\: What produces or worsens . . e\\ �. be.c>c�. . . U::X:X" .seD5 . . .0CD.c. ��b' , . 'c:::e.&c \� . . IT'C Ce\X"f'ru.s . . . "" . . p'&.\O�L\\. t . . . . raT . . . lLQc::::,EDe.o . C o n s t a n t symptoms
W h a t stops or
I nt e rm i ttent
reduces .
I
Pu"\'"
. . . . . . . . .Ce-�t .
Better
C o n t i n u ed u s e m a k es t h e p a i n P a i n at rest
eYeS
Dist u rbed n i g h t
/
Yes
Other q u e s t i o n s . . .
Trea t m e n t t h i s e p i s o d e P revi o u s episodes
. . .
"::J ®
No
CS<2E.\h
N o EHect
�-\\ '-\ --\e.::s.
. . . . �bl.e.--\: ,::s. . . X C;L ; \:x:::o\h N"\'-...l c.h
P rev i o us trea t m e n t
. . . . . . �. . .
M e d i c a ti o n s : tried
. . . . . . D5 .� \ D. . .
\.<:::5'S
.
�o �W\ , .
. . \OC
<::: � . . . �.5 . .
S p i n a l h i s t o ry . . . . . .Dc::c-.e.
Present m e d i c a t i o n G e n eral h e a l t h
Imagi ng . S u m m a ry :
.
P a raesthesia
E H ect
. . . . C\0P\ \ .D. . .
.<=\.� . .
. X· cn.>..\ iD\\-Y:o..\\.,",,\ , Acute
/�
S i t e s for p h ysical e x a m i n a t i o n
..
C h ronic
.
. co
\....K.... CR:C�r-.
�,+ .I.O�'-...l(,-\ �
l ns i d iouS onset
.
yes ®
'-.
C O M M O N D I S O R D E RS
C H A PT E R
..
Active movement Loss .
ERP . .
. . POM..
.. P�G()t&c\'h�CC\.,. C.O,s,t\eX_\GC\'r .\0.�_C5\C:C- . , . . . .e\..\e\.5\c:c- . E:R.e ��C 'o��
Passive move m e n t L o ss ( +I-over-p ressure)
P\ \\
....
. \\�\\Eod c.:\u.e.. -:\-Q \y&D �
. .. ..-
&\\
ERP
POM
.. .... ... P�'\:C:\c�\e:k\QD
TEN
\D�\<;:;c)
...
.
a::a �"
.
.
��"'-*�\ .
R e s i s ted tests R e s p o n s e
. 81\\ �\a\'uL
Effect of repeated t e s t s
on
C'c:0 - �� \:::e.a�\� ...::e.'L�� - � �' \9
i n creas e s ,
abolishes.
produce s .
pai n :
d ecre a s e s , no
worse,
better,
localises,
radiates,
u
�\! \-c:::, e
Effect of repeated tests on m o v e m e n t -
ClSl__\-:::'�
.
Better
better,
n o e ffect
no worse,
\0C_�� .
��� �"
. . . .\.\XS��",e . .
Worse
.
..
.::e . .ra . . �
. . .\:"C:)
No
Static P o s i t i o n i n g E ffects
Loaded I
U n loaded .
SPINE M o v e m e n t Loss .
Effect of repeated
E ffect
of static
movements:
posi t i o n i n g :
G
CONCLUSION Dysfunction :
U (periPherai]
retevan
S p i n e testin g :
u r .. .
A rt i c l a
I Relevant
I
S e c o n d a ry pro b l e m
BD"'-\e..
..
Postural .
Derangement Ot h e r
Spine
Contractile
\ :C'1\E£n.\
\,<;""'--\�� . .�. �b .:c-c. . .
U n c e rt a i n
...
PLAN Exercise
O We::,
�\'::'�
F re q u ency
-e. . . . c,co�.N.�. . . -- . . . . �'--
LGE':::> . �cl:\Ge. �>r�
. . . . . . . . . X . . \0 . . . .
.
><-, . \ 0 .
..
.
.... . . .
.
. .o/+. ><- 3/4 . x.
.. �
Effect
1 271
1
272 C H A PT E R T E N
T H E H U MA N E X T R E M I T I E S : M E C H A N I CA L D I AG N O S I S
& T H E RA PY
11
:
Ct-IAPTER ELEVEI'i
Clinical Reasoning
Introduction Cli ni c al reason i ng is the cogniti v e and decision-making process involved in clinical practice, which is us ed in the diag nosis and
management of patient s p rob lems ( Te rry and Higgs 1993; J ones '
et
al. 1994) It is the pro cess by which health care provide rs respond by logic and thought, rather than by routine and habit. Studies of clinical rea son ing in the medical field have shown that it tends to be
a process of hypothetico-deductive reasoning ( Terry and Higgs 1993) This describes a process of hy po th e s i s generation based on
information gath e re d from the p a t ie nt The h yp ot hesis is then test ed .
out or further ones generated until a managemen t pathway is c lea r ly
defined
Because hypotheses must be con lirmed by responses to
treaLment, the process involves continual re a ssess m e nt. In effect, every treatment is a form of hy po t h esi s tes t i ng Oones
1992)
An alternative model of clinical re asonin g is based on pattern reco g n it i on Oones 1 992) Equipped with a well org an ised knowledge base, certain features in a clini cal presentation remind the clinici a n of a previ ou s pattern of presentati on Thus m a nage m e nt strategies
are derived from previous experience rather than an experimental
'try
it and see' model There are thus
two models of clinical reasoning
hypolhetico-deductive log ic and patte rn recognition The la tter is only poss ible with a well organised knowledge b a se and is only
available to experts, while the former approach can be used by novices
O ones 1992)
[n the face of atypical problems, whe n pattern
recognition is not possible, the expert reverts to hypo t hes i S test ing As a means of determining management strategi es pattern recognition ,
can h ave drawbacks. Failure to fully explore all o p tion s and bias for a
fa v our ite diag nosis can encourage p rem a t ure foreclosure on
alternative hy p otheses
.
Pattern recogn i tion, on its own, may be
insufficient if it ignores certain complicating factors such as ex agg erate d fear-avoidance.
Clinical re asoning is informed by cert ain factors These include data gatherin g skills, aspects of the knowledge base available to the
clinician, clinical experience and meta-cognition skills (Terry and Higgs 1993;Jones
1992 ; Jones et al. 1994) It is thus a complex and
1273
274[ CHAPTER
ELEVEN
THE
& THERAPY
HUMAI'J EXTREMITIES: MLCHANICAL DIAGNOSIS
cyclical p rocess as su gge sted by t he model of clinical reasoning for
p hy siot h erapy p rop os ed by J o nes (1992; J on es et al. 1994; J one s and B utler 1991). At every stage in this process errors may occ u r that cou l d affect the reliability or v alidity of the reason i ng process
Oones 1992)
On a practical leve l clinical reasoning is the p rocess of d eci d in g what problem the pa tient has and, [rom y our k nowl edge base, d e c id i ng
what can be done about it. F i rst this involves the d iscove ry of the '
c h a rac t er of that problem '
-
the p at ien t is the bes t witness to this,
and data ga the ri ng skills must be ca p able of determining a clear 'big -
pic ture
'.
Second, a rounded know le d ge base is needed to provid e
practitioners with an understanding of diverse factors such as a va riery
of clinical presentations, the n a t u ral hi s t ory of
a condition,
p a t h o physiological changes, man a ge ment strategies, the evidence
base, the effect of an intervention, etc. The third and vital element is the ability to reason between the practical reality of the patient'S proble m and the available k no wl e d ge base. This involves constant interplay between t h eore tic a l concerns and clinical issues and a logical
an alys is of the e ffect of int e rv e n tion strategies on the problem. Clinical re ason i ng is thus an essen ti a l element in the translation of c linica l theory int o clinical practice, and an exploration 01- i ts key elements is vi tal to make full use of any a p proach to
a
patient's problem
Elements that inform the process of clinical reasoning Data-gathering This is the process of d isc ov e ry about the p at ie nt s p robl e m '
undertaken d ur in g the hi s tory t a k i n g and the p hysic al examination. -
The pa t ient has availa b le the esse nce of the probl e m ; the ski l l is in a ccessing it Certain aspects of ques t io n ing will be rou tine
Other
elements may need developing for the individual pa ti ent and the evolving hyp o the S iS
.
Questioning needs to be done in an o p e n
manner, rather than usmg lead in g questions. Communication skills
a re vital in this area; clinicians m ust provide an e m pat h e tic and l isten i ng ap proac h to access the full information
U se ful enquiry
st ra tegies incl ude op en en ded questi ons, forci n g choices, minimal -
encouragement, repetition of the pat ien t s language summarisi n g and '
,
silence. Closed qu estions may be used secon d a r il y to probe in more detail or to clarify specific points
Research has shown that
CLINICAL R.EASONING
CHAPTER ELEVEN
m anip u lative physiotherapists overuse closed enquiry techniq u es, which limit patient responses, at the expense of open enquiry methods, which encourage patients to voice their concerns (Haswell and Gilmour 1997) From the history-taking an overall picture of the pa t ient s condition should have been gained, and the direction '
that the examination is to proceed in should be suggested. The phy sica l examination is not a routine series of tests performe d
uniformly on every patienL, but follows on directly from the data gathering and hypothesis-testing of the hi.story knee test on a patien t who has knee pain is as unhelp fu l and as illogical as gathering every scrap of information about the patient's medical history Data coll ect ion continues until a decision can be made about management strategies. The decision may be tentative, in
which case further data will be gained at th e next session and
from the patient s response to the proposed management strategy '
Oones 1992;]ones et al. 1994; Terry and Higgs 1993).
Knowledge base C l i n i cal practice requires a wiele rangi ng breadth of knowledge from -
different areas. However, for the knowledge to be of value in the e lu ci d at io n of the patient's problem, it m u st have clinical relevance. Very often what is learned in train i ng may have only a slight bear ing
on wh at is cl one in the clinic. What is signi ficant and what is irrelevant is only learned through clin ical experi ence Theoretical knowledge .
mu st have pr a ct i cal significance for it to be of worth. 1 t is suggested U ones
et
al. 1994) that the follOWing topics are of
relevance to the k no wl e dge base of physiotherapy - anatomy, phYSiology, pathophysiology, proced u r e s , patterns of clinical presentation and concepts Also, hypothesis-making h a p p ens in six key areas - the mechanism of symptoms, differential diagnosis, predisposing
or
cont r i b u t i n g
[ac tors,
pr e c a utio n s
and
contraindications, management and prognosis Oones and Butler 1991Jones 1992;]ones et al. 1994). It is suggested that this is not a complete list; clinical pract ice also needs to be informed by knowledge about epidemiology, the research evidence, p sycho logical issues and communication with patients. An y of these factors, and more, may provide useful cl i ni cal information on d i f fere nt occasions. However, their value rests on
1275
2761 CHAPTER
ELEVEN
THE HUlvlAN
EXTREMITIES: MECHANICAL DIAGNOSIS & THERAPY
their clinical appli catio n rather than their theoretical strength. The value of so me of the more important aspects of the knowledge base will be presented to exemplify their practical worth. Epidemiology
This area provides bac kgrou nd knowledge about the
prevalence of a condition and its likely natural hisLOry and clinical course. This information is limi ted in many musculoskeletal
co mplaints However, what is known makes clea r that frequently .
such pr ob l ems are very widespread and can have a persistent or recurren t history This needs to be translated into an appro p r i a te management strategy that r ecognises that such persistence may arise desp i te or even because of previous trea t ment In effect, the outcome .
needs re formulating from how to 'cure' this patient or abolish their pain to the b est strategies available for this perso n to manage their chronic disorder. Evidence-based physiotherapy
It has been said that be c au s e
physiotherapy prac tice has been so poorly evaluated and rests largely upon theoretical hypotheses, sp o ntane o us improvement due to the passage of time, and subjective impressions that "today 'phYSiotherapy science' is still an oxymoron" (Sala 1997)
Research into current
practice is cert ain ly inadequate and often inappropriate. H o w ever
as a pro fessi o n
,
,
physiotherapists must rec o gnise that the future
fu nding and allo cati on of scarce healthcare resources will u ltima t e ly only be end o rsed if the evi dence is ava ilab le to support such use. Partial as it is, the evidence a lr e ady
a vail
able giv es clear indications
of the way we should be approaching musculoskeletal p ro bl e ms
.
From a wide range of r a nd o mised controlled trials and systematic reviews quoted widely in this text, it is apparent that many co mm o nly used t reatments provide only short-term r e l ief -
,
if any Passive
thera pies such as ultrasound and ot her electrotherapy modalities
appear to be so widely
a ssoci a ted
'vvith l ack of treatment effect, ap a rt
from placebo, that such approaches may need to be abandoned co mpl etely. Active, exercise-based appro aches are co nsistently across ,
a variety of dis o rders able to generate a positive treatment effect, so ,
that the gener a l direction of phYSiotherapy management stra tegies should be clear. When this evidence IS considered in the light of other sources of evidence such as epidemiology and the role of
psychosocial factors, any other appro a ch appears to be based on habit and training rather than log ic The theo ry provided by research gives .
CHAPTER ELEVEN
CLINICAL REASONING
practical guidelines for the development of the science of physiotherapy Differential diagnosis
Awareness of possible causes of a symptom
complaint is necessary to direct treatment towards the appropriate structure. Groin pain may be due to problems in the lumbar spine, the hip, the sacroiliac joint, the adductors, or o t h e r non musculoskeletal conditions. Effective management must be directed towards the source, which is accessible through taking a thorough history and mechanical tesLing of the dilTerent structures. However, within this context it is important to be aware of cenain issues that obscure the clarity of a p r e cis e diagnosis. In chronic problems me chan i c ally produced symptom responses may be confusmg and unclear (Zusman 1994), the validity of musculoskeletal tests is largely
unprove n and they frequently lack reliability In particular, intertester ,
reliability of observation, palpation and identification of anatomical landmarks has been sholATfl to be poor These problems should not dete r clinicians from offering treatment; however, there should be caution about dogmatic diagnoses. There should instead be acceptance of proposing manage ment with a non-specific diagnosis or with a syndrome classification. Concepts
Using the McKenzie approach requires an understanding
of the mechanical syndrome classIfication. The postural, dysfunction and derangement sy n dro m e s describe clinical presentations and responses to specHic mechanical loadin g strategies - in other words, they describe what happens Their clinical value, gained once the clinician is able to recognise them (using the tools of elata-gathering anel cognition), is their use in proposing management guidelines Confirmation of a proposed syndrome hypothesis is gained by expected responses to the applied loading strategy Absence of a purely mechanical response to loading suggests the need for further hypothesis generation. Is an acute or sub-acute problem still in an inflammatory slate' Is a chronic problem, which is easily aggravated by little movement Just like an acute problem, actuall)! showing the hypersensitivity and deconditioning characteristic of many chronic problems? Is failure to respond due to non-mechanical factors that the clinician has not been aware of and which have not been suffiCiently addressed? Failure to detect a purely mechanical problem sugg ests the consideration of non physiological factors, such as psychosocial issues.
1277
2781 CHAPTER ELEVEN
THE H U MAN EXTREMITIES: MECHANICAL
DIAGNOSIS & THERAPY
Is i nter m itte n t p ain due to postural factors, a d y s fu n c t i o n or a d er an geme nt? As above, a l ogical a nalysis of the symptomatic and mechanical resp onse to diff eren t end range load in g st rategies helps -
to cl assify t he p rob l em and leads to the fo rmul ati o n of a m a nagement p la n If t h e response does not fit 'vvith the classification, has a no n .
mechanical fac t o r b ee n omitted fro m the a n a ly sis or is further testi ng ,
appropriat e ! Use of the standa rd i sed terms when assessing the symptom response and the Traffic Light G ui de give a safe a nd logic al format for developing a nd pr ogressi ng a m anage m ent programme. Communication with the patient
This includ es data-gathe ring
techniques mentioned above, as well as the prov i s i on of informa tion ,
Data-ga thering requires emp a thy and act i ve li ste ning by the clinician. Unless the situation is relaxed, friendly, respectful a nd n o n judg emen tal, the p a tient is unlikely to tell the whole true story. Unless questions are o pen and inviting all responses, even the ones you
might not want to hear, the clinician may be in ca pab l e of hearing t h e true story and may not obta in commitment from the patient to the treatment.
The specifics of information provision vary b etwee n patients Find out what the y want to know as well as what t he y should know, and what their p a rticu lar concer ns and worries are - make sure these issues are addressed. Self-management re qu i r e s support, encourage ment, e xp la nat i on and education to provide the means for the patient to analyse their problem. Individual patients will vary in their
par ticular requirements, but successful self-manageme nt is unlikely without this input. Psychosocial factors
Knowle d ge of the role of psychosocial fac t ors
in t he development of chron i c muscul oskeletal problems should be translated into cl inical prac tice by seeking to address these issues from the outset. Key factors such as fear-av oidance behaviour, low self-efficacy, external healt h locus of con tr ol a nd passive coping need .
to be addressed by an ap pro ach that encourages activity, provides reassurance and e xp la n a tio n , and offers some control in managmg
their problem. Equally
it must be
recognised lh at sometimes these
factors are so do mi na nt that a multi-di.scipli nary approach may be necessary Mechanism of symptoms
Pain may be p re do mi na n t l y rnechanical
in origin or pre do min ant ly chemical S ymp t oms may be modulated
CLINICAL
REASONING
CHt\PTER
s tron gly by pain behaviours dic tate d by the higher c e ntre s. Neurophysiological changes in the central nervous system may be the cause 01' persistent symptoms when peripheral tissue damage is resolved Patients with these different problems will describe different presen tations and will respond differently to mechanical loading. The clinical value of knowing abou t mechanical, innammatory and chronic pain states is the ability to perceive these different clinical presen tations, and thus the different management gu ideli nes that these dIfferent presen tations need . Pathophysiology
It is important to know the normal healing process
that Follow s tissue in.iu ry and the factors t hat may retard healing T his needs to be translated into an active, exercise-based approach to patient's rehabilitation. The knowled ge t hat join t capsules, contractile structures an d other soft tissues can respond to disorders by the developmen t of contractu res, adhesions and scarring is vital to ou r un derstand in g of chronic musculoskele t al problems Knowledge or typ ical areas of pain that emanate from pathology at certain sites gives a focus for the physical examination. Some pathophysiological concepts are essential to an understanding of musculoskeletal conditions The normal healin g process, the necessity of remodelling to regai n full function, the problematical nature of tendon healing, and the recogni tion of non-mechanical factors in chron ic pai n are examples of such concepts that have wide relevance. SpeCifiC pathophysiological problems relevant to individual conditions are add ressed in Chapter Ten. Management of these conditions is imp roved with an understanding of t hese issues . Contributing factors
Various factors may have a role 10 causation
or prolonging the patien t's problems These may be static or dynamic postural forces that can be interru pted, such as occupational or domestic stresses. Sometimes workers are unable to interrupt work routines for fear of endangering their jobs . Pre-existing overuse or degene rative changes may also be cont ributory factors t hat are less amenable to alteration. Speci fic contributing factors to di fferent conditions have been discussed previously, especially in Chap ter Ten. In those mu sculo skeletal problems that do have a clear occupational aetiology, an inability to break from those aggravating factors is likely to augur a poor outcome. However , sometimes the pat ient assumes a causative
ELEVEN
1279
280
I CHAPTER
ELEVEN
THE
THERAPY
HUMAN EXTREMITIES: MECHANICAL DIAGNOSIS &
role to exercise or activity which on close questioning is not apparent ,
Careful assessment and mo nitoring of possible causative and co n trib uting factors would seem obl igato ry This text has concentrated almost entirely on
Procedures
procedures performed by patients rather than cl i n ici ans. Various exercises have been mentioned, described, or photographed in t h e
text
-
it should be noted that
not all exercises that could be used
have been p h otographe d or described. This is not
a
'
recipe book' of
proced ures to apply in al l situations. Exercises described under one condition may be used for another, if appropriate Not all procedures .
that may be used in all circumstances have been descr i bed At t im es it will be appropriate to find different procedures that suit the patient
in front of you. As long as the reasoning and assessment process is gone throug h, exploratory exerCIses may be safely introduced to addr ess the particu lar problem of the patient. Patients may present as classical examples of condit i ons described '
'
in the chapter on common disorders, and respond to the guidelines in a textbook '
'
way frequently t hey will not. Nonetheless, an
u nd er s t a n din g of the concepts of mec han i ca l di ag nos i s and assessment of symptomatic and mechanical p resentations should allow the safe introduction of exercise man age me n t Clinical experience
Clin ical reasoni ng requires clinical experience It is only having see n hundreds of pati ent pres en t at ions that pat terns 'vvill be recognised,
and skills of data-gathering will be m ast ere d and focused into hypotheSiS generation and confirmation However, clinical experience can also lead to rigid thinking and failure to countenance unfamiliar presentations Pattern recognition is not about squeezing square pegs .
into round holes, but continually re-evaluating data to confirm or deny a proposed hypotheSiS. Clinical experience of itself does not necessarily lead to improved c l ini cal reasonin g
.
Cognition and meta-cognition Cognition refers to the thinking processes involve d
in data-gathering,
the applicat i on of a knowled ge base and clinical experience. It is this
thinking process that guides clini cal d ec ision makin g and thus -
,
proficiency in thi s area should lead to better p a t ient managemen t.
Me ta-cognition re fers to re nect ion durin g the clinical process and monitoring of thinking processes (Terry and Higgs 1 9 9 3 ; J o nes et at.
CLINICAL REASONING
1994)
CHAI'TER ELEVEN
II is not enough to know things in theory; their translation
into clinical practice only comes with reflective reaction.
Errors in clinical reasoning Errms in the thinking process may occur at any stage during data gathering, analy sis, hypothesis-generation and testing These may
be errors o[ perception, enquiry, interpretation, synthesis, planning or rellection Oones 1992) Examples of typical errors are making assumptions without further checking, prematurely limiting hypotheses under consideration, failure to gather enough infonnation, attending to those features that accord with a favoured hypothesis while ignoring contradictory information, and gathering redundant information Oones
19 92)
Failure LO listen carefu\\y to a patient may mean ignoring a key piece
of information and a false trail of hy pothesis-generation Focusing on the traumatic onset of a condition may lead to the assumption that the stages of inflammation, repair and remodelling must be gone through, ignoring the fact that a derangement may be the cause of symptoms Doing every available lest is a common way of gathering redundant infonnation that the clinician is unable to use to fashIOn a treatment direction
It is important to question openly and listen
without making assumptions The use of the form focuses the data gathering on certain key areas, which should be sufficient in most cases, and aVOIds the gathering of redundant information that will not help in decision-making. DaLa-gathering skills vary with different presentations Sometimes close quesLioning concerning symptomatic responses to loading strategies is necessary to determine the correct management strategy
At other times, in chronic patients, a close focus on pain is less relevant, and the attention should be on function The failure to find a favoured presentation should not lead to trying to squeeze patients into diagnostic boxes that they do not fit. Do not make clin ical decisions without sufficient information. If pattern recognition is not immediately available, revert to hypotheSis-generation tactics. Use repeated movements and progressive loading to determine the appropriate management strategy Equally, do not begin to change a management strategy without haVing first fully explored the patient'S response
1281
282
1 CHAPTER
ELEVEN
THE
HUMAN EXTIUMITIES: MECHANICAL DIAGNOSIS & THERAPY
An example of clinical reasoning In the following e xa m ple a d esc ript i on of the f ind i ngs from the data
gatheri ng is given in normal type After each section some instan ce s of the clini cal reasoning that these issues may prov o ke is gi v en in
italics. History-taking A 5 5 y ear o l d man is re ferr e d by h is GP with neck and a rm pain He -
-
had worked in metal engineering for fifteen years inJobs that involved s u stain e d postures, with his arms fre q uent l y in raised and ov e rh ead positions. He had two weeks off work near the b eg in n i ng of Lhe episode on the 'doctor's ord e rs
',
after which he was a bit better He .
had re mai n ed at w or k on a different Job that involved less overhead work. He usually pl ayed gol f once a week, but ha d sto p ped since the o nse t of the p robl e m ; he hadn't been given any clear advice on whether to play again or not. He had played a few roun ds a month previously and although it had hurt more for a couple of days it then
felt better for about a
w
ee k He was keen to resume playing golL On
the assessm ent tools his pain visual analo gue score was 4, on a 0 to
10 scale, and on the Croft Shoulder Scale (Croft eL aL 1994) fo r measuring functional p roble ms he
had marked six out of t'iNenty
two activi ties. Psychosocial factors
His reluctance to be off work
and brevity of suggests
sick leave when it was encouraged, despite ongoing symptoms,
that issues about 'yellow flags' can be discounted. This is endorsed by pain visual a na logue scale and functional
the correlation between his
disability score. He is keen to have advice about returning Lo his f avourite hobby. These aspects suggest he will be well motivated to perf orm an exercise programme. His present symptoms were two separate areas of pain, l o ca l right sided neck pain and also in t he top of his r i ght am1, in the area of his
d el to i d muscle. He felt his a rm pain was his main co mplai nt: this had develo p e d insidiously six months previously and remained at
the same site, with occasional referral of pain to Lhe e lbow. After an initial improvement in the first few weeks, th e condition has been
overall unchanging. In the last thre e or fo u r weeks he d eve l o p ed neck pain, which he felt was not related, and which was in fact now improving. Initially his arm symptoms had been con stant but had ,
been intermittent in recent m o n t h s He esti mated he felt iL about .
CLINICAL REASONING
CHAPTER
30% of the day Shoulder movements b rought on his arm pain, but he could move the limb fully The arm p ai n was broug ht on by raise d
-
a rm
activities, such as putting
on sweatsllirLs or J ackets reaching into the back of the car, or pulling ,
the bathroom li ght switch, which he did by lifting his arm sideways. Some lifting a ctivities at work also provoked it G enerally the pa i n stopped when he ceased the activity but if he persi sted sometimes it ,
ached for an hour or so afterward s Also sometimes it ached in the .
evening after work . A lth ough generally it eased when he rested the arm, pain always retur ned with the same activities. There was no clear diurnal p attern, althou g h sometimes it worsened as the day went on and some days it got easier. One or two nights a week he was woken by it, which he thought was due to lying on the right
side The neck pain he felt was a se parate problem
,
which now only
troubled him intermittently on neck movements Moving the s pine .
had never affected the pain in the top of his arm. Pathophysiology
The patient s age and occupation and the insidious '
onset of symptoms suggest an underlying degenerative component to his problem. This may have imp li c at ions for prognOSiS Mechanism of symptoms
A predominantly mechanical problem can
be suspected, with the intermittent pain p rod u c e d by consistent activities.
Contributing factors
His work i s likely to be a contributory factor
in causation an d maintenance of his problem However, he is not in a
position that allows him to easily change careers so rehabilitation ,
has to take place alongside his continuing occupation Primary site
W here he is feeling the pain suggests that his primary
problem is at his shoulder Shoulder complaints are commonly felt in the top of the arm. The neck pain seems secondary and to ,
him a
separate, lesser and resolving problem. The aggravating factors for his primary complaint also focus attention on the shoulder. Stage of condition
This is in the chronic stage. This may have
implications for prognOSiS and the timescale of any improvement.
ELEVEN
1283
2841 CHf\PTER
ELEVEN
THE HUMAN
EXTREMITIES:
Status of condition
MECHANICAL DIAGNOSIS & THERAPY
This is unchanging. The stage and status oj the
condition m ean that a reasonably vigorous approach should be used in this man's rehabilitation. He may experience a temporary worsening
prior to improvement as occurred when he tried to play golf. Loading strategies and target zone
His list oj aggravating Jactors
has given a clear indication oj the area in which his problem can be loaded and targeted. Symptomatic presentation
His pain visual analogue scale,jul1ctional
disability score, daily duration oj symptoms, and aggravating activities give a range oJbaseline measurements against which impr ovement or lack oj it can be judged. State of the tissues
Although in the chronic stage, this man seems
to be suJJering a prim arily mechanical problem, possibly related to contractile dysJunction. Non-mechanical Jactors appear to be irrelevant.
A reasonable 'big picture' of this man and his problem has been gained
from the initial part of the history-taking, and allhis stage no further questions pertaining to divergent hypothesis generation need to be made He had attended a private physiotherapist [or a few weeks which had involved ultrasound and mobilisation. This made his arm feel belter [or a brief period, but he stopped going as overalJ it wasn't really improving. He had had no previous history of ann or neck pain apart from this present episode. His doctor had provided him with two courses of NSAlDs. The first course in the I"irst month, accompanying his two weeks 0[[ work, seemed to have helped somewhat; it turned [rom an 'ache to a pain' A more recent course
of anti-inOammatory medi.cation made no alterati.on to his symptoms, but he had stopped as he started to develop indigestion and heartburn He is taking no medication at the moment. He considers his general health to be good. Apart from his recent visits to the doctor about his shoulder he had hardly been at all in the last ten years. There had been no x-rays or investigations. Previous treatments
It is unclear iJ the
initial improvement was dlte
to the rest Jrom work or the NSAIDs, but either way this medication
C H A PT E R
C L I N I C A L R E f\ S O N I N G
had not resolve d hi s p rob l em When tak e n later .
it had no affect on his
symptom s. This confi rms t h a t t he prob l e m has no inj1 a m matory component, as would be expected at this s tage Pas s i ve physi o the rapy t reatment had also been of no benef i t . Thi s again confirms earlie r thi n ki ng that a rea s on ably vigo rous rehab i l i tation approach s hould be i n s t i ga ted S ummary
Th is i s a ch ron i c condit ion wi th an in si di ou s onset, which
is at p r es e n t unchanging. The prime s i te for phy s i c a l exa m i n a ti on is the s h o u lde r, but the ce n' i ca l spine w i ll have to be defini t ely ru led out and the refo re needs to be examined also.
P hysica l exa m i nation There is m in i m a l loss o f c e r v i c a l extension and righ t ro t a tion , and b o th movements produce his neck p a in All o ther cervical movements .
are Fu ll and p a i n - fre e . U p o n r e pea t e d extension movements the ri gh t s i d ed neck pain i s p r o d u ce d
,
b u t h i s ran ge i n c r e ase s
.
The p a in
p ro g ress ive l y lesse ns and subsequ e n tly r i gh t ro t a t i o n is e asi e r A t no .
time w htle t es t i n g ou t his cervical s p in e is the arm p a i n fel t , and
following the rep e a led ex t e n s i o n the pa i n on moving his a rm is u n c h a n ge d Spine testi ng
T h i s has rev e aled an unre l a ted s e condary p rob lem,
n a mely a res o l v ing ce rv i ca l derangement. A d v ice needs to be given on t he approp r i a te ex te n s i on exerci s es , but the neck pa in is clearly not relevant to his primary problem , w h ich is at the s h oulde r. Acti ve m o vements of his shoulder ( flexion , abduction , hand u p th e b a c k a n d adducti o n a r e tes t e d) reveal a ful l , or nearly full, ran g e in
a l l p la nes . This is c o n fi r m e d by p a ss i ve l y testing l a teral ro tation and gleno - h u m eral a b d u ction, whi ch a re also the same as the l e ft arm . There IS pain during m o veme n t with flexion and abduct ion , and at end- ra n ge lateral ro t a t i o n . Differential diagnosis
The full range ac tive and passive move m e n t s
discou n t res tricted shoul d e r conditions, namely caps u l i ti s . The s i te of pa i n an d that a d d u ct i o n is p a i n -free discO Lm ts the acromioclavicular joint. F in d i ngs so far, su ch as these negative findings and the painfu l arc, begin to focus on s ubacromion s tmctures . Epidemiology
P robab ly the mos t common disorder at the s h o u lde r
i n volv e s the rotator cuff. These problems are frequentl y pe r s i s te n t and resista n t to �Is u a l ther apy.
E LEVEN
1285
286 1 C H A PT E R E L E V E N
TH E
H UMAN
E X T R E M I T I E S : M E C H A N I CA L D I A G N O S I S & T H E RA I' Y
Resisted tests pro d u ce t h e p a t i e n t s p a i n s tro ng l y with ab d u c tio n '
,
a n d less so w i t h l a teral ro ta t i o n All o t h e r re s i s t e d te s ts are p ainless .
Upon repea ting resis t e d abduction ten times the ann pain i s p rod uced each time b u t fad e s away wi thin a c o u p le of minu tes of s t o p ping
Abduction t hrou gh the arc o f p a i n , o r ta rge t zone , was also repeated ten time s . Again each movemen t was p ai n fu l , but a ft e r a few m inu tes he d i d n o t rem a in w o rs e . His res p o n s e to d iffe ren t l oading s t rategies,
Mec han i cal p resentation
nam ely a c t i v e fl exion and abdu c t i on, res i s ted abduction and la teral r o t a t i o n p r O V i des m o v e m e n t s aga i n s t w h i c h a ny c h a nges in h i s c o ndition c a n be c ompa red D i ffere n t i al diag nos is
.
A suprasp i natus c o n d i t i o n is c o nfi rm ed w i t h
t h e p rimary p a i n bei ng rep ro duc ed w i t h res i s ted abduc ti o n . Th e response to l oadi ng t h i s tiss u e w as t h a t of a dy sfu n c t i on (pa i n p rod u c e d a n d not w o rs ened) , w h i c h confi nn s earl i er hypo t h e s i s ge ne rat i o n N o fu rt h e r t es t i ng n eed b e d o n e at t h i s s tage, a s n o c o n t r a d i c t o ry i nfo rm atio n sugges ts o t h e r w i s e. R epeated movem e n ts
Th e m o v e m e n ts t h at w er e s e l ec t e d to b e
repeated w e re t h o s e that loaded t h e abnormal t i s s u es, w h i ch w e r e the s o u rc e of h i s pain, m axi m a l ly . Thes e h a d b een ga rn ered fro m t h e l1 i s t o ry - ta h i ng a n d p hy s i c al exam inat i on . Self- management st rategy
Thes e m o v em en t s p rovide the s ta rt i n g
p o i nt for t h e p a tie n t s exe rcise p rogram m e . '
E d ucation a n d active mechan ical therapy T h e p a tient is i n fo rmed that it l o o ks l ike a te ndon p ro blem , whic h is part of t h e m u s c l e , and tha t i t hasn't heale d u p pro perly It needs to b e w o rke d r e g u la rly b u t n o t e xcess i ve ly to stimulate t he he a l i ng a n d bloo d n o w a n d t o try t o s trengthen i t again fo r normal u s e . A s the p roble m has been p resent fo r some ti m e and b e c a u s e i t invo lves a tend on who se healing pro per t ies are not very go o d , a q uick re sol u t i on i s not to be expect e d . As ha ppene d when he p l a y e d go l f a n initial ,
tempor a ry worsening o f his sym p t o ms m a y o c c u r, b u t ther e i s n o ca u se to worry ab o u t t h i s as long as i t sett l es clown a fter a day o r two . He i s keen to res u m e p l a y i n g golf an d that wi l l b e the t a rge t fo r h i s rehabili ta t i on The p a t i e n t is given ac tive abduction exercises t h ro u gh t he
a rc
of
p a i n He i s t o l d t o re peat t his t e n tim e s every t w o h o u rs . He p ra c tices
C H A P T E R EL EV E N
C LI N I C A L It E A S O N I N G
t h is so he is clear about what he shou l d do. He is given the opportunity to ask any ques tions. D u e to work commi tments he is not able to a t tend fo r revievv unti l the follo w ing week Information provis ion
It i s i mportant that the patient is told n ot only
what to do b u t why , wh i c h i n c l udes s o m e info rmation about t he p rob l e m i ts e lf. He needs to be gi ven guideli nes as to how often he s ho u l d pe ljorm t he procedu re a n d what l i h e ly response he may get He m u s t practi ce i t a n d be gi ven an oppo rtunity to as h any othe r q uestion s . He m u st be warned t hat if t h e re is prog ressive i n c rease and wo rsen i ng of his sy mp toms o v e r the next Jew day s , he m ust cease exe rc is i ng until re v i e wed again .
Review
1
O n his ret u rn the pat ien t says he has managed to perform the exe rcises abo u t six lim e s on most d a ys He is asked to demonstrate 'vvhat he .
has been d o i n g and shows that he has been doing it correctly The ,
first few days h is arm fe l t more so re and ached a bit more fre quently, b u t then t h e exerc i se became easier. Now it still ach e s about 2 0 % o f t h e d a y b ut i t i s less severe t han i t was . Pain i s p roduced b y the same ,
activi ti e s . O n ph ysical exam i n a t ion Dexion is n o w pai n - fre e , b u t there is sti l l a p a i n fu l arc on abd ucti o n . No rap id c h a n ge wo u l d be expe c ted i n this c o n d iti o n, s o t h e symptomat ic and m ech anical presentation is not l i hely to have changed m uc h . Initi a l ly th e re was a temporary agg ravati on oj h i s sy mpto ms, a common occ u rrence in c h ronic tendon p roblems . He Jeels the exerc ises are h e l p i ng . O v e rall diagnos i s and m anage ment is c o nJi rmed as approp r iate and the same strategies shou l d be continued. At th is s tage the only conside ration i s w h e t he r to i nc rease the Jo rce by add i ng a we ight, b ut t h i s is deemed u nnecessary as the sy mptoms a re s t ill being eas i ly p rovohecl by t h e p resent exerc ise. He w ill c onti n ue with the same plan and be re v i e wed in one wee h .
Review
2
At the secon d rev iew the p at i e n t re ports t hat t h e e xerc i se g o t progre ssiv e l y easi er a n d now hard ly h u rts a t a ll . He still fe e l s the pam i n his arm occaS ionally (less th a n 1 0 % o f the day) , but several act ivities t hat were painful no longer cause any p roblem . Active Dexion and abdu c t ion no longer p rovoke h is pai n . There is sligh t p a i n on resisted ab d u ction , none on resisted lateral ro tatio n . He has found
t h e most pain fu l movement to be lateral rotation pe r formed at 9 0
1287
288
1 C H ArTE R
E LEVEN
T H E H U M A N E XT R EM I T I E S : M EC H A N I CA L D I AG N O S I S & T H E R A ry
degrees ab d u c tion . When ab du ctin g th ro ugh the t a rget z o n e with a small weight in his hand some p ain is also p ro d u c e d .
H e i s c o n t i n u i n g t o i m p ro v e - sy mp t o m a t i c and m ec ha n i c a l pres entations, and his a n aly sis oJ his problem all attest t o this. At this point the exercises are not suJJic ient ly load i ng t he tiss ues to p ro voke pa in; consequen t ly they need to b e progresse d. It m u s t also be seen iJ he can retu rn to go II N ew exerc ises a re given - a b d u c tion thro u gh t h e ta rge t z o n e w i t h a smal l weigh t , and late ral ro tatio n in 90 degrees abduction. He is unable to re turn fo r two we eks, a n d so is also e n c o u r age d to p l a y a few rou nds of go l f b e fore re tu rni ng.
Review
3
He reports that when he Jirst s tarted to do the new ex e r c i s e s i t w a s initially a bit m o r e sore, but this didn't c o n c e rn h i m as h e was Jo rewa rned and i t had happ e n e d befo re. As he c o n t i mled over the Jol lowi ng week it got eas ier, and now when exerc ising the arm only hurts s lightly . Apart Jrom w hen doing the exe rc i s e h e hardly Jelt the arm p a in at alL He had not been woke n by it i n the last wee k . He had p l ay ed a Je w rounds oj golJ the p re v i o us weekend a n d only h ad occas ional t w in ge s Upo n repeat i n g the assess ment tools h i s pa i n v i s u al a n a l ogue s c ore w a s n o w 1 , a n d o n t h e Ju n c t i o n a l d i s a b i l i ty q u est i o n n ai r e no activiti es were still a problem. He was happy to be di s c ha rged at this p oi n t .
.
Conclusion Clinical reasonmg is ab o u t the deCision - ma k i n g t h a t o c c u rs
in a
clinical situ ati on. It is not a static , one - o fF event , b u t a dyn a m i c process involving proposed manage ment strategies and re - assessment o f resp onses to these pro p osa ls I t i s u n d e r pin ne d by a sound k n o w ledge base . I t re quires good data-gathe ring skills, b o t h in history-ta king and i n p h ysi cal e xa m i na t i o n . I t re q u i res the ab i l ity to recogn ise c o m m o n p atterns of c l i n i c a l presen tatton su c h as dys func tion o r derangement , bu t also t h e abi l i ty to ge nera te a l t e r n a te hypot heses
if the presentation is e qui v o c al. This needs good re- assessment skills and a n ab ili t y to closely analyse patient'S me c han i c al and symp LO m a t i c p rese ntations
C o gn it i v e skills are a n esse n t I a l tool
in the
i n t e r p l ay b e t ween t h e o re t i c a l concer n s a nd c o nce p ts a n d the p ra c t i c a l i n t e r p re t a t i o n of p a t i e n t 's p r o b l e m s an d p r o p o s e d manage ment stra tegies
REFER.ENCES
References
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Stevens Mj (1989) Acute and chronic pain Paio dimensions and
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New York. AdchaJo AO, Hazleman BL (1992) Soft tissue shoulder lesions in the African.
Br]
Rheum 31.27'\-276. AdebaJo AO, Nash P, HOlleman BL
(1 990)
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placebo controlled study comparing triamcinolone hexacetonide injection vvith oral cliclofenac 50mg TDS in patients with rotator cuff tendonitis.
J
Rheum
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Yassi A ( 1 9 9 7 ) . Repetitive s t r a i n i nj u ries. La n c e t 3 49 . 9 4 3 - 9 4 7 . Z i m m e r m a n n M ( 1 9 89) . P a i n mec h a n isms and med iators i n osteoa rth ri tis , S e m i n a rs
i n A r t h r i t i s and Rh e u m a t i s m 1 8 , 2 2 - 2 9 .
Z u s m a n M ( 1 99 2 ) , C e n t r a l nervous system c o n t ri b u t i o n t o m e c h a n i c a l l y p ro d u c e d m o t o r and s e n s o r y responses Aus ] P hy s i o 3 8 . 2 4 5 - 2 5 5 . Zusman M ( 1 994) T h e m e a n i n g o f mec hanica l l y p ro d uced responses. A ust J P h ys i o
40 , 3 5 - 3 9 .
G l o s s a ry of Te r m s
Dera n g e m e n t sy n d ro m e I m e r n a l disloca t io n of artic ular tiss u e , o f whatever origi n , tha t c a u s es a d i sturbance i n t h e normal res ting p osition of the a ffe c te d j o int
s u r fa c e s
.
T h i s d e fo rms t he c a p s u l e an d p e n a r t i c u l a r su p p o r tive
ligamems r e su l t i n g in pain , which will remain until s u c h t i m e as t h e d i s p lacement is r e d u c e d o r a d a p t i v e c hanges have remo d e lled the
d i s p l a c e d tissu es. Im ernal dislocation of articular tissue o b s tru c ts m o v e m e n t a t t e m p t e d tow a r d s the d i rection o f d i s p lacement .
D i rect i o n a l prefe re n ce Used to d escribe the p he n o me n o n o f pr e fe re n c e for move men t i n
o n e d i rection , which i s a characte ri s tic o f t h e d e r a n g em e n t syn d rome . I t descr i b e s the situ a t i o n whe n movements in o n e d i re c t ion will improve p a in and the li m i t a t i o n o f range , whereas movements i n the o p p o s i te d i re c t i on cause si gns and symp toms to worse n .
Dysf u n ct i o n s y n d ro m e N o rm a l mechani c a l d e fo rm a t i o n o f st r u c t u r a l l y i mpa i r e d s o ft t i ssues that r e s ul t s in p a i n . This abnormal t i s s u e may b e the p ro d u c t o f p re v i o u s trau m a , o r i n fl am m a t o ry o r d egene rative processe s . These
evems cause c o ntr a ct i o n scarring, adherence or a d a pt i ve shortening. ,
P a i n i s fe l t when the abno r m a l t i s s u e is l o a d e d . Dy s func t i o n s may be l o c a te d in a rti c u l a r or c ont ra c t i l e tiss u e .
Iatroge n i c d i sa b i l ity S y m p t o m s o r d i s a b ili t y i n d u c e d in p a ti e n ts by the t re a t m e n t or comme n t s o f a clinician ( o r i ginally a p h y si c i an )
.
Load i n g strateg ies Describes the a p p l i e d movements , positions or loads required to s tress p a rticular stru c t u re s ; may be d yna m i c o r stati c . For exampl e , in the
case of arti c u l a r s t ru c t u res this may be e n d ran ge a ctive m o v e m en t , -
or fo r c o n tractile stru c t u re s t h is m a y b e a resisted tes t .
Mec h a n i c a l p re s e n tat i o n O u twa rd mani festati o ns o f a musculoskeletal prob l e m , s u c h as loss
of movement range or velocity of movemen t , and fu nc t i o n a l disabili ty resu lting from c o nd i t i o n Very i m p o rt a nt in re -assessment o f treatment .
effi cacy
31 2 1 G LO S S A RY O F T E R M S
T H E H U M A N E XT R E M I T I E S : M E C H A N I CA L D I AG N O S I S & T H E RA PY
M ec h a n i c a l re s p o n se Behavi o u r o f m e c han ica l prese n t a t i o n , lo r instan c e m oveme nt loss , i n response to a particular lo a d i n g s t ra tegy.
N o n - m e c h a n i c a l factors In t he a c u te phase o f a p ro ble m the pai n -gen e ra t i n g mecha nism ma y b e p rim ari l y i n fl a m m a t o ry. I n t he c h r o n i c s t age v a r i o u s n o n m e cha n i cal fact o rs , s u c h a s
ce n
t ral o r p e r i p h e r a l se n s i t i sa t i o n o r
ps y chos oc i a l fac t o r s , may be m a i n taining the p ai n .
Pain A wte pain Pain of r e cen t o n se t , l ess tha n seven d a y s a n d thus p re d o m i n a n t l y ,
i n O a m m a t o ry. S ub - awte Pain that has lasted b e twe en seven days and seve n weeks , and may re present an in te rfa ce b e tween i n O a mmator y and mecha nical p a i n C h ronic p a i n P a i n t h a t h a s l a s t e d fo r l o n g e r th a n s e v e n w e e k s ; t hi s ma y b e m echanical o r non-mech anical i n nature . C h ronic pain states Pain of lo n g d u ra t ion in w h i ch non-mecha n i c a l fac t ors a re i m p o r t a n t in p a i n m a i n tenance . These fa c t o rs may rel a te to peripheral o r c e n tr a l sensit isation or psyc hosocial fac t o rs , such as fe ar-a v o i d a nce , e t c . C h e m ical o r i nJ1am mato ry pain Pa i n m e d i a t e d b y t h e i n flam ma to r y che m i c a l s rel eased fo l l owing tissue d a mage .
M e c h an ical pa i n Pain that resu l ts from mechanical de fo rmation o f ti ssues . T h is o cc u rs wi th abnormal stresses on n o rm al tissue s , and n o rm a l stresses o n abnormal tissu e s , s u c h as oc c u rs i n d e ra nge m e n t a n d d ys fu nct io n
.
Constant pain Constant pain d escribes sym p toms t h a t a re p resent th ro u gho u t t h e patie n t s waking d a y, wi tho u t a n y res p i t e This m a y be c h emica l o r '
mec hanical i n o r igi n a n d also ex ists i n c h ro n i c p a i n s t a t e s . ,
Intermittent pain This desc ri b e s pain t h a t comes and goes d u ring the co u rse of t he d a y. Com m o n ly this rel a tes to i n termittent and pain .
m ec
h a n ic a l d e fo r m a tion
T H E H U M A N E X T R E M I T I E S : M E C H A N I C A L D I AG N O S I S & T H E RA r y
Loca l i s a t i o n of pa i n This describes t he a b o l i t i o n o f d i stal , widespre a d o r d i ffuse pain and its move m e nt or localisation towa rd s the site of the p ro b l e m as it resolves
Post u r a l s y n d r o m e M e c h a n i c a l d e f o r m a t i o n o f n o r m a l s o ft t i s s u e s o r v a s c u l a r i nsu ffi c i e n cy a r i s i n g [rom prolo nge d positi o n a l o r postural stresses , a ffe c t i ng any a rt i c u l a r o r con tra c t i l e stru c t u res and res u l t i ng in p a in .
Stage o f c o n d i t i o n
A l l m us c u l os kele t a l c o n d itions can be anywhe re o n the c o n tin u u m fro m acute to s u b - ac u te t o ch ronic . These stages a re o ften o f more s i gn i ficance to manage m e n t t h a n a s t r u c t u ral diagnosis .
Sta n d a r d i sed t e r m s T hese a re used to m a ke consis t e n t d escrip t i o ns o f s y m p to m a t i c resp o nses to d i Ffe re n t l o a d i n g s trategies to J u d ge the i r v a l ue fo r sel f t rea t m en t .
Sta n d a rd i sed te r m s u s e d to d e s c r i be sym pto m beha v i o u r : D ur i ng loading: In creas e
S y m p toms a l rea d y present a r e increased i n intensity
D e c rease
S y m p t o m s a l ready presen t a re d e c re ased i n intensity
P ro d u c e
M ove m e n t or load ing c reates symptoms th a t were not p resen t p ri o r to the t es t .
Abolish
Movem e n t o r l o a d i.ng abolishes s y m pto ms that w e re p rese n t p r i o r to t he tes t .
Afte r loadi ng : Wo rs e
S y m p t o ms produced or increased with moveme n t o r l o a d i ng re main worse fo l l O Wing t h e tes t .
N o t Wo rs e
S y m p t o ms p roduced or increased wi t h movement o r loadi ng d o n o t rem a i n wo rse follo w i n g t h e tes t .
B e t te r
S ym p toms decre ased o r a bo l i s h e d with movement o r
Not Better
S y mp toms d ecreased o r abolished w i t h movement o r
load ing a n d rema in better a fter testing l o a d i ng a n d do n o t remai n better a fte r testi n g . No Effec t
M o v e ments o r l o a d i n g have n o e ffe c t o n s y m p t o m s d u r ing o r a ft e r tes ti.ng .
G LO S S A RY O F T E R M S
131 3
31 4 1 G LO S S A RY O F T E RMS
T H E H U M A N E X T R E M I T I ES: M E C H A N I CA L
D I A G N O S I S & T H E RA P Y
State of tissues
This d e scribes the di fferent conditions that tissues cou l d be i n . T h ey ma y be n o r ma l o r a bn o rm a l A b n o rmal tissues may be i nj u r e d .
,
he a lin g scarred or con t ra c te d wi th healing suspende d , h yp e rse nsi t ive ,
,
to normal loading d u e to c h a n ges i n the nervous syst em , de ge ne ra t ed o r p a i n fu l d u e to a r ticular derangeme nts .
Status of co n d i t i o n This describes the direction t h e condition i s g o i n g re lative to re covery
It may e i th e r be impro vi ng , w o rsen ing o r unchangin g . Its status i s si gn i fi c a n t to decis i o n s abou t management .
Sy m pto matic p resentation T h i s d e s c r ib es t h e d e tails o f t h e pa t i e nt s c o m p l aints a n d can b e '
assessed and re-assessed regardi n g site , tem poral co mponen t , severi ty a n d c o n s e q u e n t a n a l g e s i c /N S A I D c o n s u m p t i o n . T h i s is v e r y imp o rtant i n r e ass e ss m en t o f tre a tment e ffi c a cy -
Sym pto matic respo nse The behavi our o f pain in res p o nse to a p a r t i c u l a r l o a d i n g s t rategy
Ta rget zo n e The p a rt o f the range of move ment where maximal p a i n i s p ro v o ke d This i s a c h a r ac t er i s t i c o f s o m e contractile d y s fu n c t i on s and a t a rge t fo r l o a ding stra t e gies fo r re m o d e l l i n g
.
Traffi c L i g h t G u i d e I d e n t i fi c a t i o n o f p a t i en t s resp o n ses t o l o a d i n g s t ra t egies u s i n g '
s t a n d a rd i s e d t e r min o l o g y d e te rmin e s the a p p r o p r i a t e n e s s o f a m a n a g e m e nt d i re c tion . If the p a ti e n t rema ins worse a ft e r war ds this
i s a red ligh t ; if the p a t i e n t remains better this i s a g reen ligh t I'o r th a t
exercise ; if there is no ch a n g e more fo rc e may be re q u ired . Ye l l ow flags Te rm used to d e sc r ib e psychOSOCial r i s k fac t o rs fo r d eve l o p i n g or
per p etuating l o ng t e rm d i s a b i l i t y o r sick leave as a c onse q u e n ce of -
musculoskele ta l symptoms They include fac t o rs such as the a t t i tudes
and bel i e fs of the p a tient abo u t their p roblem , their behav i o u ra l re s p o nses t o i t , in a p p ro p r i a te h e alth c a re a d v ice , and r e la t i o n s w i t h
fa mily a n d work .
I n dex
A
C
A c h i l l e s ' te n d o n i n j u rie s 2 4 1 -2 4 5 m a n a ge m e n t , se l f- t re a t m e n t
Capsu l a r pattern 1 1 0 C a p s u l i t is ( fro z e n s h o u l d e r) 1 5 , 2 l ,
64 , 2 0 4-2 1 4
exerc i ses 2 4 3-2 4 5
and
A d d u c t o r/gro i n s t r a i n 2 38-2 4 1
a ge
91
assess m e n t s he e t s 2 1 1-2 1 4
m a n agemen t/se l [- t re a t me n t
c l m i ca l m o b i l i s a t i o n s 2 09-2 1 0
2 40-2 4 1
m a n a ge m e n t 2 0 5- 2 0 6
Age
n a t u ral h i s t o ry 2 0 5
m n u e n c e o n h e a l i n g process
no n s t e ro i d a l a n t i - i n fl a mmat o ry
3 1 -32
-
d r u gs
i n fl u e n c e o n i n l u ry 9 1 A l l o d yn l a 6 4 , 7 5
An k l e s p ra i n s
see
(NSAl Ds) 2 0 5-2 06
p re va l e n c e 204 La t e ra l an k l e s p r a i n s
A n i c u l a r d e ra n ge m e n t synd rome
e xe rcises 2 0 6-2 1 0
2 2 4-2 2 7
1 69- 1 8 1
c o r t l cos t e ro i d i nj e c t i o n s 2 2 7
c h ro n i c p a i n s t a t es 1 8 2- 1 8 4
m a n age m e n t 2 2 6-2 2 7
ed u c a t i o n/se I f- m anage m e n t
n
1 7 1-172
a t u r a l h is t o ry 2 2 6
a n d pregnancy 2 2 5
manage m e n t 1 84- 1 8 5
C h ro n i c p a i n
se l f- t re a t m e n t 1 7 2 - 1 7 9
d e fi n i t i o n 1 2 8- 1 2 9
A r t tc u lar d ys lu nc t l o n
manage m e n t 1 84 - 1 8 5
e d u C a t l o nisc I f- manage m e n t
p rese n t a t i o n 1 5 4- 1 5 5
1 4 5- 1 62
sensitisa t i o n 85-86
se l f- t re a t mem 1 5 8- 1 6 2
states 7 5 -7 7 , 1 4 6 , 1 5 5- 1 6 1 ,
Asse ss m e n t m ec h a n i c a l prese n ta t i o n a n d
sel f-treatment
C a r p a l t u nnel synd rome 3 5 , 1 4 8 ,
1 8 2- 1 8 5 IlS
assess m e n t 1 2 5 sym p t o m a t i c p rese n t a t i o n a n d assessme n t 1 2 3- 1 2 6 sy m p t o m a t i c re s p o n s e 1 2 6- 1 2 8 te r m i n o l ogy fo r d e s c r i p t i o n o f
s y m p t o m responses 1 2 6- 1 2 7
C l i n i c a l re a s o n i n g 2 73-288 c l i n i c a l e x p e n e n c e 280 cogn i t i o n a n d m e ta-cogn i t i o n
2 80-2 8 1 d a ta-ga the r i n g 2 74-2 7 5 e rrors in reas o n i ng 2 8 1
hypothesis
genera t i o n 2 8 1
k n o w led ge b a s e 2 75-2 7 6
B B l ops y chosocial m o d e l o f p a m 6 0
B u r s i t i s 2 3 2- 2 3 3
p a t t e r n re c o g n i t i o n 2 8 1 Co l l a g e n 2 2-2 7 , 6 7 , 1 5 1
31 6
1 1 N D�X
T H E H U M A N E X T R E M I T I E S : M E C H A N I CA L D I AG N O S I S & T H E RA P Y
ro l e i n m u sc u l o s k e l e t a l p l'O b l e m s
C o m m u n i c a t i o n 89�9 0 , 1 8 5 ,
]91
2 7 4�2 7 5 , 2 7 8 C o m pl i a n c e 1 39
D i re c t i o n a l prefe re n c e
d e fi ni ti o n 3 1 1
C o n n e c t ive t i s s u e e x e rc i se a n d s t ress d e priva t io n
D isa b i l i t y assessm e n tih i s t O lY 9 J. -92
2 8�3 0 recove ry fo l l o w i n g trau m a 2 1 �2 5 C o n s t a n t t i ssue d do rmat i o n 6 7�68
D u p u y t re n 's Co n t rac t u re 2 3 1 - 2 3 2 Dys fu n c t io n s y n d l'O m c 8 2 -83 a b n o r m a l t is s u e 1 5 4- 1 ') ')
C o n t ra c t i l e d y s fu nc t i o n
a r t i c u l a r d y s fu nc t ion 82-8 \ ,
s e e M u sc u l o t e n d o n o u s
1 5 6� I S 7
d y s fu n c t ion 1 6 1 � 1 62
c h a ra c t e rist i c s ym p t o m rc-ponse
C o n t ract i l e t is s u e
8 2�83
c u m u l a t ive t ra u m a 3 4
c o n s t a n t pam 9 7�98
d e ra nge m e n t s y n d rome 8 3 �85
c o n t r a c t i l e d ys fu n c t i o n 8 2�8 3
d ys fu n c t i o n s y n d ro m e 8 2 �83
see
l o ad i n g 3 2 � 3 5
a l so m u sc u l ot c n d o n o u s d y s fu n c t i o n
p ost ura l syn d ro m e 8 2
d e finH i o n 8 2 �8 3 , 3 1 1
C o rt i c o s t ero i d i njec t i o n s 1 5 , 1 6 , 2 1 6 ,
re p e a l e d m o v e m e n t 82�8 3 ,
227
1 1 8- 1 1 9 , 1 5 6
C u m u l a t i ve post u r a l s t ress 3 2
E
D de Q u e rv a i n 's S y n d r o m e 3 5 , 2 2 8 - 2 3 1
s e e a l s o Te n osynov i t i s Dege n e ra tive c h ange 2 1 5 pa t i e n t h i s t o ry 9 5 Dege n e ra t i ve j o i n t d i sease 1 5 7 ,
2 5 5�2 64 s ee also O s t e o a rt h r i t is
E d u c a t i o n , pa t ie n t 3�4 , 2 4 , 1 3 3� 1 3 7 ,
1 47, 1 5 1�152 re h a b i l i la t i o n a d vi c e 2 6 , 8 5 -8 6 ,
1 3 4- 1 3 5 seH- m a n agemen t , pat i e n t 3�4 , 1 7 ,
20 E l bow d e ra n ge m e n t
see
'Pse u d o '
t e n n i s e l bow
Degenera t i ve t e n d o n o p a t h y 2 7�3 5
E le C l ro l h e r a p y
D e r a n ge m e n t s y n d rome
E n d - fee l 1 9 , 1 J 2 � 1 1 4 , 1 6 1
a r t i c u l a r t issue 8 4 d di n i t io n 83�8 5 , 3 1 1
i n t ra - a r t i c u l a r 1 5 5
see
U l traso u nd
E n d - ra n ge pa i n exe rcise/m ove m e m 8 6 , 1 05� 1 0 9 ,
1 1 2� 1 2 1 . 1 5 6� 1 5 7 , 1 7 1 � 1 7 9
j o i n t s 83�85
E p i d e mi o l ogy 1 8 2 , 1 8 5 , 276
m a nage m e n t 8 4�8 5
E x e rcise 2 9-3 2
p a i n 84 , 1 1 6 , 1 4 1
ben e fi ts 3 6 , 86
re p e a t e d m o v e m e n t 8 4 , U 8
com p i i a nce/n o n - c o m p l l a nce
Diagnosis 1 9 1 d i ffere n t i a l 2 7 7 m e d ic a l lll o d e l 79-87
1 3 6� 1 3 lJ i n d e rangeme n l s y n c! ro me 84�8 6 ,
1 72
n o n-speci fic 8 1 , 1 9 J
in d y s fu n c t i o n syn d ro m e 8 6
a n d post u r a l s y n d ro m e 8 2
i n postu ral s yn d ro m e 86
r e li a b i l i ty/va l i di t y 1 6- 1 9
T H E H U M A N E XT R E M I T I E S : M E C H A N I CA L D I A G N O S I S & T H I RA P Y
p ro g ra m m e 2 6 , 7 2 , 1 0 1 , 1 0 6 ,
m a n a ge me n t 6 6-6 7 , 1 49 - 1 5 0 s o ft t issue 1 49
1 0 7 , 1 1 7 , 1 1 8 , 1 30 , 1 3 5 , 1 6 7 - 1 69 , 1 8 2- 1 8 4 , 2 0 6-2 0 7 ,
I n n e r v a t e d t i s s u e 3 4 , 6 1 , 7 0 , 83
2 0 9 , 2 1 6-2 1 7
I n t e r m i ttent tissue d e fo r m a t i o n 2 4 ,
re v i e w p roCE',s/s)' m p t o m res p o n se
1 3 0- 1 3 1
69-72 I n t ra - a r t i cular d e r a nge m e n ts 1 5 5
s e l f- m a n age m e n t 2 1 9-2 2 1
I nt r a - a r t i c u l ar s t e r o i d s 2 06
se l f- t re a t m e n t 2 0 6-2 0 9 , 2 5 2
Isch a e m i a 3 1 , 3 3 , 8 2 , 2 2 7
t h e ra p y 1 6 , 1 3 7 , 1 4 1 - 1 4 3
K K nee see Pa t e l l o fe m o r a l j o i n t p a i n
F Fract ures 3 7 , 5 4- 5 5 , 9 4 , 1 0 3 , 1 4 9 ,
L
265 function
La t e ra l a n kle s p ra i n s 2 6 5-2 7 1
fac t ors rest r i c t i n g re t u r n t o n o r m a l
assess m e n t s h e e t 2 7 0-2 7 1
fu n c t i o n 30-3 2
m a n age m e n t 2 6 5-2 6 6
F u n c t i o n a l d i sab i l i t y 9 3
se l f- m a nage m e n t 2 6 7- 2 6 9 Late r a l e p i co n dy l i t i s (' t e n n i s e l bo w ' )
H
2 1 , 3 5 , 6 7 , J 4 8 , 2 1 5- 2 2 3
H a e m <1 l O m 3 3 1 , 1 1 2 , 1 6 2
assess m e n t s h e e t 2 2 2 - 2 2 3
Heal i n g
n a t u ra l h i story a n d clinical c o u rse
i n h i b i t i o n o f p rocess 3 1 , 2 7 9
216
p rocess 2 4 , 30-3 2 , 6 5 , 1 3 4 ,
see
and pat h o p h y s i o l o gy 2 7 9 rest 64-66
a lso ' Pseu d o ' t e n n is e l b o w
s e l f- t reatment 2 1 6-2 1 8
1 5 1-152
Ligaments t e s t s 1 1 3- 1 1 5 Loa d ing s t ra t e g i e s
H e a l t h c a re use 7, 1 0- 1 3 , 2 0 , 2 1
d e fi n i t i o n 3 l J
H e a l t h l o c u s o f con t ro l 3 2 , 1 3 4 ,
1 3 9- 1 4 4 , 1 8 2 , 2 7 8 H i s t o r y - ta k i n g/i n te r v i e w i n g 89- 1 03
M M a nage m e n t and s e l f- t re a t m e n t
aims o f 90
145-189
t he i n t e rv i e w 9 1 - 1 03
acu t e p resenta t i o n s 1 49
pe r i p h e ra l assessm e n t sheet 1 0 4
c h ro n i c p resen t a t i o n s 1 5 4
H y per a l ge s i a 6 4 , 7 5
education 1 5 1- 1 5 2 manage m e n t 1 49- 1 5 0 sub-acute prese n t a t i ons 1 5 1
I a t roge n i c d i sa b i l i t y 1 3 9 , 1 8 9
Mechan i c a l d i agnosis 79-8 7
d e fi n i t i on 3 1 1
m e d i c a l m o cl e l 79
i n a p pro p ri a t e b e h a v i o u r o f healt It
n o n - mecha n i c a l c o n d i t i o n s 85-86
pro fe ss i o n a l 2 3 5- 2 3 6 I n n a m m a t i o nlc h e mi c a l pai n 63-6 7 ,
8 5-86 b e h av i o u r 64-66 c r i te ria 66-67
non-spec i fi c 8 1 ro le i n m u s c u l o s ke l e t a l p ro b l ems
79-8 J Mecha n i ca l e va l u a t i o n 1 0 7- 1 0 8
I N D FX
1317
1
31 8 1 N D E X
T H E H U MA N E X T R. E M I T I E S : M E C H A N I C A L D I A G N O S I S & T H E R.A PY
a e r i ve movem ent 109-1 1 1
N e u ro l ogica l e x a m i n a t i o n assess m e n t s h e e t 1 22
n e u ro l o g i c a l e xa m i n a t i o n
1 1 9-120 ove r p ressure 112- 1 1 4
N o ci ce p t i o n 5 9-60 N o n-mec h a n i c a l c o n d i t i ons 85-86 a c u te pain 85
pass i v e m o v e m e n t s 1 1 1 - 1 12 res i s t e d tests 1 1 4- 1 1 5
c h romc p a i n 85 , 1 2 8- 1 29 d e fi n i t i o n 312
M e c h a n i cal p a i n 62-63 c o n s t a n t , c h e m ica l 63-6 4
N o n- me c h a n i c a l fac t o rs d e fi ni t i o n 3 1 2
behavi o u r 64-66 c ri t e r i a 63-64 c o n s t a n t , m e c ha n i cal 67-68
N o n -s pec i fi c d iagnosis 81 N o n - s t e ro i d a l a n t i - i n fla m m a t ory d ru gs ( N SA I Ds) 1 4, 1 5 , 206; i n
be h a v i o u r 6 8-69 and d e ra n g e m e n t 74-75
Capsu l i t i s 204
i n t e r m i t t e n t 69-72
Osteoa r t h r i t i s 258-2 5 9
a b n o r m a l tissue 7 1 -72
P a t ell o fem ora l j o i n t pain
b e h a v i o u r 70
245-24 6 , 25 1 Ro t a t o r c u ff t e n d o n i t i s 1 9 6
c r i teria 69 n o nn a l t issue 70-7 1 a n d m e c h a n i c a l syn d ro mes 82 -85
Mec h a n i c a l prese ntation 123-131
o O s t e o a rt h ri t i s ( d e ge n e ra L i ve j o i n t
d e fi n i t i o n 3 1 1
cond i ti o n s ) 1 0, 1 5 7, 25 5-264 asse s s m e n t s h e e t 263- 2 6 4
M e c h a n ica l response 86-87, 13 1 ,
1 42 , 182 , 277
m a nagement 257-260
d e fi n i t io n 3 1 2
N S A l D s use 258-259
M e d i c a t i o n 31 , 1 0 1 , 102 , 138 , 2 1 6 ,
se l f- m a n age m e n t exerc ises
260-262
258-2 5 9 M u scu l os k e l e t a l cond i t i o ns
O veruse i nj u ri e s ( RS I/c u m u l a t i v e
d i a g n o s i s p ro b lems 18- 1 9
t ra u m a d i s o rd e rs) 25 , 1 4 6- 1 47,
n a t u ra l h i st o ry a n d c l i n i ca l c o u rse
23 3-23 7 e rgo n o m i c h a z a rd s 82 , 91, 234
1 4- 1 6
low-load muscle a c t i v i t y 234-23 5
p reva l e nce 7-20 by s i t e 1 2 - 1 3
manageme n t 237-238
i n o l d e r p o p u l ation 1 1
N S A IDs/co n i co s t e ro i d i nj e c t i o n s
psyc hosoc i a l fac t o rs 277
238
s i te o r 7 , 12 , 1 3 M us c u l o t e n d o n o u s d y s fu n c t i o n 1 5 6 ,
1 61
p Pain 5 9-77
e d u ca t i on/se l f- m anage m e n t 1 62
assess m e n t o f 9 2 - 1 02, 1 2 3-] 2 5
s e l f-trea t m e n t 1 62-168
b e h a v i o u r o f 70-72 , 1 52 ,
trea t m e n t 1 68
1 82- 1 85 , 207 c h e m i c a l 6 3-66
N
c h e m i ca l/mec h a n i c a l
N a t u ral h i s t o ry 1 4- 1 6 , ] 96 , 205 , 2 1 6 ,
22 6 , 249-2 50
d i ffere n t ia t i o n 63-6 4 , 67
c o n s t a n t 6 7-68 , 9 7-98, 1 28- 1 29 d e fini t ion 3 12
T H E H U M A N E XT R E M I T I E S : M E C H A N I C A L D I A G N O S I S & TH E RA PY
d u ra t i o n 1 4 1 - 1 4 2
assessme n t fo rm 1 2 2
i n l1 a m m 3 1 O ry p a i n , i d e n t i fica t i o n
mecha n i ca l e v a l u a t i o n 1 0 7- 1 0 8 n e u rological exam i n a t i on
o f 66-6 7 i m e r m i lt e m 69-7 2 , 74-7 5 ,
1 1 9- 1 2 0
o b s e r va t i o n 1 0 7
9 7-98 , 1 2 3 , 1 4 2
me c h a n i sm o f sym p l O m s 2 7 8-2 7 9 m e d i c a t i o n 1 02
p a l pati o n , role o f i n 1 0 8 Physio t h e r a py, e v i d e n ce - based
n o c i ce p t i o n 5 9- 6 4 non - m e c hanical c o n d i t i o n s 85-8 7
2 7 6-2 7 7
Postura l p a i n 96
acute 85 , 9 4
abnormal tissue 7 1-72
c h ronic 8 5 , 9 4
norm a l t i s s u e 69-7 1
sub-acute 9 4
P o s t u r a l stress
o n set o f 1 4 2 - 1 44
avo i d i ng b y e x e rcise 1 3 6
psyc h osoC i a l fac t o rs 7 5 - 7 6
s e e a l s o Con t ra c t i l e tissue 32-3 5
re l ievi ng/a ggra v a t i n g fac t o rs
cumulative 32-35 dynamic 35, 8 2 , 1 4 8 , 2 5 1 , 2 7 9
98-99
o n m us c u l os keletal t issue 3 2-3 5
re peated m o v e m e n L , inf1uence on
s t a t i c 3 5 , 82 , 2 3 8 , 2 79
99 , l l 5 - 1 1 9
s o u rces 6 0-6 1
Post u r a l syndrome
Pa l pa t i o n 7 9
c o n s t a n t pain 9 7-98
P a te l l o femoral J o i n t p a i n 2 4 5 - 2 5 4
d e fi n i t i o n 3 1 3 e d u c a t i o n/se l f- ma nage ment a n d
assess m e n t s he e t 2 5 3- 2 5 4
t re a t m e n t 1 4 5 - 1 89
c l illl cal p rese n t a t i o n 2 4 8- 2 4 9 manage m e m 2 5 0-2 5 1
m e c h a n i c a l d i agnosi S 8 2
m e ch a n i c a l d iagn OSis a n d t h e ra p y
n o nnalla bn o r m a l tissue 1 4 6 ,
2 5 1 -2 5 2
1 5 4- 1 5 6
n a t u ra l h i s t o ry 2 49-2 5 0 :--.l S A l D s 2 5 0
rep e a t e d m o v e m e n t 8 1 'Pse u d o ' te n n i s e l b o w 2 1 8- 2 2 3 assessme n t sheet 2 2 2-2 2 3
Patient
se l f- m a n age m e n t e x e rcises
ac t i ve m e c h a n ical t h erapy
2 1 9-2 2 0
1 3 7- 1 3 8
c om m u n ication 2 7 8
s e e a l so La teral e p i c o n d y l i t is
e d u c a t i o n 1 3 3- 1 3 6
Psychoso c i a l fac t o rs a n d p a i n 7 5 - 7 6 ,
m a n a gemem 1 3 3- 13 6 , 1 4 3- 1 4 4 ,
311
1 4 5- 1 8 9
se l f- m anage m e n t 1 45- 1 8 9 e x erc i s e c o m p l i a n c e/n o n c o m p l iance 1 3 8- 1 3 9 s e lr-trea t m e n t 1 45 - 1 89 p ro c e d u res 1 4 8 spec i fic requ i re m e n ts fo r
R Repeated movement a p p l i ca t i on t o d e r a n gement synd ro m e 1 1 8 a p p l i c a t i o n to dysfu n c t i o n a l synd ro m e 1 1 8
i n fo r m a t i o n 1 3 3- 1 3 4
a p p li c a t i on to m e c h a n i c a l
s ta t u s o f c o n d i t i o n 1 40 - 1 4 4
d isord ers 1 1 5- 1 1 8
Phys i c a l e x a m i n a t i o n 1 0 5- 1 2 2 a i ms o f 1 0 6- 1 0 7
a p p l i c a t i o n to p os t u ra l sy n d ro m e 1 18
I N D EX
1 31 9
32 0
I I N D EX
T H E H U M A N EXT RE M l T I E S : M E C H A N l C A L D I A G N O S I S & T H E RA P Y
syndro me resp onse to 8 5 ,
i n ll a m ma t i o n 2 2 , 2 6
1 1 8- 1 1 9
i nj u ry 2 1 - 2 3 , 2 6 , 3 0 , 7 4 ,
Res t , l e e , Co m pre s s i o n E l eva t i o n
1 48- 1 5 0 , 1 5 4
,
( R I CE) p ro to c o l 2 2 , 9 5 , 1 5 0 , 2 4 0 ,
overview 2 1 - 5 8
2 4 3 , 2 6 6-2 6 7
re m o d e lltng 2 3 - 2 7 , 3 1 , 3 6 , 3 7 ,
R o t a t o r c u ff t e n d o n itis 1 5 , 1 9 3 -2 0 3
6 7 , 72-73
assess m e n t s h eet 2 0 2 - 2 0 3 cause 1 9 3- 1 9 6
s t re ss d e p r i v a t i o n 2 8-30 Spinal p ro b l e m s 7 , 8 , 1 2 , 1 3 - 1 4 , 9 2 ,
m a na ge m e n rlse l f- tre a tm e n t 1 9 7-2 0 1
1 0 1 , 103, 1 2 5 , 1 82
Stage and s t a t u s o f d i s o rde r 66- 6 7 ,
n a t u r a l h i s t o ry 1 9 6
80, 8 1 , 90, 96, 1 2 7 , 1 45 , 1 9 1 .
N SA l Ds 1 9 6
2 2 7 , 2 42
d e Ci n i t i o n 3 13
S
S t a n d a rd i sed te r m s d e fi n i t i o n 3 1 3
Se l f- e fficacy 8 6 , 1 3 4 , 1 3 6 , 1 3 8 , 1 4 2 , 183, 259, 278
S ta t e o f t i ssues
de fi ni t i o n 3 1 4
S e ns i t i s a l i o n
manage m e n t st rategy 1 4 4 , 1 5 5
central 7 5 - 7 7 , 80 , 8 6 , 1 5 5 , 1 8 2 , 235, 3 1 1
S ta t u s o f co n d i t i o n d e fi n i t i o n 3 1 4
peri pheral 6 4 , 7 7 , 8 5 -8 6 , 1 5 5 ,
i m p ro v i n gi u n c h a n g i n g/worsen i ng
1 8 2 , 2 3 5 , 3 11
6 7 , 9 0 , 9 6-97 , 1 4 0- 1 4 3 ,
Sh o u l d er pa i n
283-284
s e e also Capsu l itis c e rv i c a l s p i ne 1 2 , 1 3 , 9 3 , 1 0 2 ,
S u p ra s p i n a t u s tend o n i t i s 6 2 , 6 7 , 1 4 8 , 1 95
1 2 1 , 192-193, 224, 285
n a t u r a l h i s t o ry 1 4 p reva l e nce 1 0 , 1 1 , 1 2 , 1 3 , 1 4 , 3 3 p ro b l e m s w i t h diagnOSiS 1 8- 1 9
S y m pto m a t i c prese n t a t t o n 1 2 3- 1 2 6 d e fi n i ti o n 3 1 4 S y m p to m a t i c response d di n i t i o n 3 1 4
S o c i a l/eco n o m i c factors
d ys fun c t ion 1 1 2 , 1 5 5 , 1 9 2 , 2 3 2
i n n u e n ce on p a i n and d is a b i l i t y 9 ,
a n d e x e rcise 1 2 9 - 1 3 1
183
termi n o l ogy fo r d e s c r i p l i o n o r
Socioc u l t u ra l factors
sy m p t o m res p o n ses 1 2 6
a n d overuse i nj u ries 2 3 7 S o ft t i ss u e ab n o r m a l t issue s t a t e s 6 9 , 70-72
t o d e te r m i ne l o a d i n g 1 2 6- 1 2 7 Syste m a t i c re v i e ws 1 6- 1 7 , 2 0 , 1 8 7 , 196, 206, 2 16, 259, 276
a b o rted hea l i n g p rocess 2 7 , 3 6 , 6 7 , 7 2 , 73-74, 1 5 5 , 196
c o n tra c t i le t i ssue l o a d i n g 3 2 - 3 5
T Ta rget z o n e 1 6 3 , 1 6 4 , 1 6 7 , 1 9 7 , 1 9 9 ,
d egeneration 2 7
284, 2 8 6 , 288
fa i l u re to remo d e l 2 6 , 2 7 , 3 6 , 7 3 ,
d e fi n i t i o n 3 1 4
1 54
T H E H U M A N E XT R EM I T I E S : M E C H A N I C A L D I AG N O S I S & T H E RA P Y
re m o d e l , fa i l u re to re p a i r 73-74
Te n d o n l l i s see
R o ta t o r c u lT
se l f- treatme n t 1 5 2- 1 5 4
s e e S u p ra s p i n a t us
tissue h e a l i ng , pos t - t r a u m a
15 1-152
Te n d on s c h ro n i c cond i ti o n s 1 4 2
Tra ffic L i g h t G u ide 1 2 6- 1 2 8
susce p t i b i l i t y to In j u ry 3 2 , 3 4 , 3 6 Te nn is e l bow s e e La t e r a l e p i c o nd y l i t is
de fi n i t i o n 3 1 4 Tre a t me n ts
a nd ' Pse udo' t e n n i s e l bow
c o m m o n l y used 1 6- 1 7
Te nos y n o v i t i s ( t r i gge r li nge r) 2 1 , 3 5 , 2 2 8-2 3 J
U
see a lso de Q u e rva t n 's s y n d r o m e
U l traso u n d ( e l ec t r o t herap y ) 1 8 6- 1 89
m a nage m e n t/e x e rcises 2 2 8- 2 3 1 N S A l Ds!co rt i c oste ro i d i nJ e c t i o n s 228
T h e ra p is t lech n i q ues 1 8 5 c l in i c i a n p roc e d u res 1 8 6 pass i v e m o d a l i t ies 1 8 6- 1 8 9
Tissue t r a u m a 1 4 9-1 5 5
W Wo l ff's Law 2 9 y Ye l l ow nags d e fi n i t i o n 3 1 4
a h n o rmal t i ssue 1 5 4 c h ronic p rese nta t i o n s 1 5 4
X
e d u ca t i on/se l r- m a n age m e n t 1 5 1
X - ra y s 1 0 3 , 148
m a n a ge m e n t 1 49- 1 5 0 , 1 5 1 - 1 5 2
I N D EX
1 321
